Group Health Quoting

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Todays Date*
MM slash DD slash YYYY
Requested Effective Date*
MM slash DD slash YYYY
Business Information (REQUIRED)
Business Name*
Partnership*
- Yes
- No
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Business County*
Business Phone Number*
Average Number of (Non-Owner) W2 Employees in Prior Calendar*
*do not count owners as employees
Total Number of Full-time Eligibe Employees*
(include ALL FT/PT/Union/Seasonal)
Total Number of Enrolling Employees*
Business Startup Date*
MM slash DD slash YYYY
Nature of Business or SIC Code*

Broker Information (REQUIRED*)
Agency Name
Broker Name*
First Last
Email*
Enter Email Confirm Email
Phone Number*
Fax Number
Please check off which carriers you want MIBS to Quote
(You must be contracted with Humana and/or Blue Cross prior to quoting)
Carriers*
- BCBS of IL
- UHC LF
- Principal
- Dearborn National
- UNUM
- VSP
Tax ID #: (UHC LF Only)*
Special Instructions

Census Information (REQUIRED*)
All Fields are Required. Click on the + sign to add the additional rows.
YOU MUST PROVIDE DATES OF BIRTH FOR EVERY ENROLLING EMPLOYEE, SPOUSE AND DEPENDENT CHILD. AGES WILL NOT BE ACCEPTED.
Census Information*
Enrollee First Name Last Name DOB (mm/dd/yyyy) Gender Tier Choice Home Zip Code State Owner

All Fields are REQUIRED.

Enrollee	First Name	Last Name	DOB (mm/dd/yyyy)	Gender	Tier Choice	Home Zip Code	State	Owner

Business Information (REQUIRED)