SAGAMORE                                                                            Benefits Group, Inc.

Group Health Quote Request Form

 

EMPLOYEE CENSUS

 
Company: Contact:
Address: City:
State: Zip Code:
Phone: Fax:
Type of Business: SIC Code:
Number of FTP Employees:
 
  Name Gender Age Date of Hire Type of
Coverage		 Health Conditions
and Treatments
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
 
Please answer the following questions so that we can make an accurate comparison:
 
1. Who is your current insurance company?
2. What are your current premiums?
3. What deductible would you like quotes for? ($250 -$5000)
4. What effective date would you like?
5. Are you interested in Dental or Vision coverage?
6. What type of plan are you interested in? (PPO, HSA, etc)
Types of Coverage Codes:
 
EE= Employee Only EC= Employee & Child W= Waiving
ES= Employee & Spouse F= Family L= Life Only
 

To fax in your request, please print this form and fax it to us at (317) 818-9701

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