Insurance Agents Group Products Request a Group Health Quote Association Products Individual Products Order Supplies On-line Forms Provider Links Ancillary Services		Request a Group Health Quote Required fields are denoted with an * * Agent: * Agent's Phone: * Agent's Fax: * Choose the Carrier You Would Like Quoted: Aetna Health Assurance Highmark UPMC Health Plan Other * Group Name: * Contact Person: *Phone: *Fax: * Email: * Nature of Business: * SIC code: * Address: * City: * County: * State: * ZIP: Workers Compensation Carrier:   Current Health Insurance Carrier/Plan/Rates:   Does company offer retirement benefits?   Yes No Has company been active for 5+ years?   Yes No Did company have UPMC in the past?   Yes No Has company filed chapter 11 bankruptcy in past year?   Yes No Amount/percent paid by employer for employee:   Amount/percent paid by employer for dependents:   List All Full-time Employees: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?: Name: Date of Birth: Age: Sex: Male Female Status: Single Parent/Child Parent/Children Husband/Wife Family Opt Out?:

© 2003, All Rights Reserved, ARMS Insurance Group Inc. and Interteq.com