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Group Health Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!
Your Personal/Group Data:
 
Your Name:
Your Business Name:
Street Address:
City:
State: (Must be North Carolina)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
(If more than 5 in group, contact us at: 888-455-0674 )

Please Check the Group Products your company wants
to make available to your employees:
Group Health   Group Dental   Group Vision
Group Life   Employee Benefits

Group Underwriting Information:

Employee #1 Name

M/F

Age

Status

 

 

 

 

Occupation

Status

Currently Insured?

Plan type

 

 

 

Employee #2 Name

M/F

Age

Status

 

 

 

 

Occupation

Salary

Currently Insured?

Plan type

 

 

 

Employee #3 Name

M/F

Age

Status

 

 

 

 

Occupation

Salary

Currently Insured?

Plan type

 

 

 

Employee #4 Name

M/F

Age

Status

 

 

 

 

Occupation

Salary

Currently Insured?

Plan type

 

 

 

Employee #5 Name

M/F

Age

Status

 

 

 

 

Occupation

Salary

Currently Insured?

Plan type

 

 

 
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
 
Employee Health Problems?
(Do any of your employees have special health problems or insurance needs? If no, write "none".)
 
Group Plan Needs?
(Tell us what features you want in your group plan so that we may get the coverage and benefits you are looking for!)

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Thank you for filling out this formCOMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Group Insurance Quote NOW!

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E-Mail: quotes@blalockis.com   |   More About our Agency's Services   |    Privacy Notice/Copyright Info.
PO Box 7245 Jacksonville, NC 28540    (Click for Map/Directions)    |    Toll Free Phone: 888-455-0674
Local Phone: 910-455-0255    |    Fax: 910-455-0674   |    © 2008 Insurance-Web-Sales
Questions or web site-related problems, please E-mail us at: quotes@blalockis.com