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	We can quote on your plan. Please complete the information in this form, and we will get back to you with a quotation on a plan for your business. If you have more employees than our form can accommodate, please use our contact form to get in touch with us and we will contact you directly. Company Name   Address     State   Zip   Contact Name & Title   Phone   Fax   Email*   Do You Have Benefits Now?   No Yes Who Is The Insurer:   Average Monthly Premium:   /Employee Type Of Plan   Not Sure PPO HMO POS Renewal Month   Jan Feb Mar Apr May Jun JulAug Sep OctNov Dec What Was Increase Last Year?  % Will This Plan Be Voluntary?   No Yes   List Auto Clubs and Towing Associations you belong to   Please list all employees working at least 20 hrs per week and 10 months per year
Employee Name Or Number Date of Birth (MM/DD/YY) or age Coverage Request Number of Children Are You a Smoker 1 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 2 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 3 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 4 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 5 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 6 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 7 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 8 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 9 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 10 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 11 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 12 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 13 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 14 EE EE+S EE+C EE+F 0 1 2 3+ No Yes 15 EE EE+S EE+C EE+F 0 1 2 3+ No Yes

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