Group Health Insurance | Individual Health Insurance | 401k Retirement Plans | Employee Benefits Consultants | 630-548-3700
Serving Illinois, Wisconsin, Indiana, Michigan, Missouri, and California

Group Health Insurance Quote Research Form

Complete the form below and we will begin the process of researching health insurance options for your company.

If you are looking for individual health insurance, use our Individual Research Form.

630.548.3700 office
630.548.3188 fax



Group Health Insurance quote form:

Please fill out completely .

Address 1
Address 2
zip code
Type of Business

Current Medical Carrier
Renewal Date
Coinsurance (90/70, 80/60 etc.)
Office copay
RX card
Type of Plan (HMO, PPO, HSA etc.)
Premium Total
List any known medical conditions




For type of coverage indicate Employee Only (EE), Employee and Spouse (ES), Employee and Child or Children (EC), Employee/Child or Family (EF).
For Location, if employee lives in another state please give state and zip code.

Sex of
Date of Birth or Age
Spouse Date of Birth or Age
Type of Coverage
Number of Dependents