Group Health Quote Request E-Form

Legal Name of Business*

Full Business Address*

Legal Name of Business

Current Carrier Information (If plan is currently in force)

Upload

Current Effective Date (If applicable)

Requested Effective Date

Waiting Period

Number of Employees Currently Enrolled in Benefits

Total Number of FT Eligible Employees(W2)

Employee Only

Employee + Spouse

Employee + Children (ren)

Family

Number of Waivers (Valid Waivers Include: Spousal, Veterans, Medicare, Medicaid)

Employer Contribution %

Group Contact

Special Considerations*

Broker/Agency Name*

Phone*

E-mail*

Please note: Groups located outside NY must complete additional Employee Census