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Group Health Insurance Form
Please fill out this form to get a group health insurance quote. If you're a company and are interested in a group health plan, on your behalf we will quote through several leading health insurance carriers.




Name of Business:
 Contact Name:
E-mail:
 Daytime Phone:
Address:
 City:
State:
 Zip Code:
Association: Number of Employees:
Present Plan:
Nature of Business:
Coverage Types: (check all that apply)
Benefits:
Medical
Vision
Dental
Life

Retirement Plans
 Voluntary Benefits
Disability
Long Term Care

Please complete for all eligible employees:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Employee Name: 
 Employee Sex:
 Date of Birth (mm/dd/yyyy):
Coverage:
Please list any general comments, questions, or concerns here.


Copyright 2007 MyPlanFinder.com Health Insurance Agency All rights reserved. MyPlanFinder shops and compares Texas health insurance quotes for you and your family. Compare over 200 medical insurance plans from leading health insurance carriers. Finish your health insurance policy online or print out a health insurance application. Small business group healh insurance plan specialist. You've come to the right place for group health insurance. We have access to all types of carrier plans PPO - HSA - Copay - Short Term - Dental - Vision - Life We are adding carriers all the time to meet your insurance needs. Contact us for the affordabe term life. Offering quotes through 37 life insurance carriers. Soon to add our new domain - StateWideLife.com to serve you better. We will offer real-time instant Universal, Term life quotes through 37 different carriers. Run quotes yourself and apply with a personalized application.