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Health Insurance Life Group Short-Term
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Step 1 of 3: Medical Profile
*Indicates required field.
Business Type* Coverage Type*

Medical Plans
(select at least one)
(MMP) Major Medical Plan
(PPO) Preferred Provider Organization
(POS) Point Of Service
Optional Coverages/Benefits - (select any that you are interested in)
Dental Coverage
Maternity Coverage
Prescription Benefit
Vision Care Benefit
Current Plan Type*
Desired Deductible*
Desired Copay*
Comments / Questions
(Please indicate any specific needs you might require: i.e. Are you interested in an HMO or PPO? What kind of doctor-copay are you looking for: $10, $20?)


Step 2 of 3: Census Data
# of Employees  


Step 3 of 3: Personal Profile
Company Name*
First Name*
Address*
State*
Day Phone*
Contact Time*
 
Last Name*
City*
Zip*
Evening Phone*
Email*
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