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General Information
Legal Name of Business:
  * Contact Name:
Address:
City:   State:   Zip:
  Business Phone:   Fax:
Best Time To Call:   AM   PM
  * Contact E-mail Address:

Type of Business
Type of Business:
Standard Industry Code
(if known):
No. of Full Time Employees:         No. of Part Time Employees:
Give a complete description of any type of hazardous or dangerous duties performed by your employees:

Current Group Health Insurance Information
Carrier (Company) Name
(not agency):
Please give a brief description of your current Group Health plan:

Benefits Desired
Major Medical Deductible:     Optional Pregnancy Coverage: Yes  No
Dental Coverage: Yes  No Supplemental Accident Coverage: Yes  No
Disability Insurance: Yes  No PCS Card:
(Prescrip. Disc. Option) 		Yes  No
Group Life Insurance:

Amount: $

 Yes   No

 PPO Option: Yes  No
HMO Option: Yes  No

Employee Information
Please list all employees you wish to cover:
Employee Name
Date of Birth
Age
Sex
Dependent Status
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
If you were not able to list all employees you wish to cover,
please use the Additional Comments section below
or indicate that you will fax or e-mail an additional listing.

Additional Comments


Please click the "Submit Quote" button to send your quote request.
No coverage is in effect until bound by an insurance carrier.
This is a request for quotation only.

 

 

  
 

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Copyright © 2006
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Bramhall & Hitchen Insurance
121 Continental Drive, Suite 110   ~   Newark, Delaware 19713
Telephone: 302.995.2247     Facsimile: 302.995.2220