Reliable Health Insurance Home Page

Group Insurance Quotation
Please complete the following form and click the "Submit for Quote" button.

Company Name
First Name
Last Name
Address
City
State
Zip Code
Phone Please include area code
Fax Please include area code
Email
Nature of Business i.e. Law Firm, Advertising, etc
Number of full time employees
Number of covered employees

Current Benefits

Type of plan
Deductible $
Physician Co-Pay $
Maternity No   Yes
Prescription Drug Co-Pay No   Yes
Max Out-of-Pocket $

Complete the following census.

Employee Name Male/Female Age Type of coverage (EO, ES, EC, EF)

Medical Questionaire
Answer to the best of your knowlege.

No   Yes 1. Has anyone had a claim of $5,000 or more in the past 12 months?
No   Yes 2. Has anyone been in the hospital or had surgery in the past three years?
No   Yes 3. Has anyone been treated or diagnosed as having a serious medical condition such as:
Cancer,
Alzheimer's,
Chronic Respiratory Illness,
HIV, AIDS, AIDS Related Complex,
Cardiovascular Desease,
Muscular Dystrophy,
Mental Illness,
Diabetes,
Kidney Disease/Failure,
Cirrhosis,
Multiple Schlerosis,
Substance Abuse,
Other
No   Yes 4. Has anyone been advised to have surgery or medical treatment?
No   Yes 5. Does anyone anticipate hospitalization for any reason?
No   Yes 6. Are any employees or dependents currently pregnant?

If the answer is "Yes" to any of the above questons, please provide the details below.

Check Appropriate Box Age Nature of disorder Treatment Dates Treatment/Prognosis
Employee
Dependent
Employee
Dependent
Employee
Dependent

 

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or concerns