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					                       Name of Employer___________________________________________
                       Street address______________________________________________
                       City ____________________State ______________Zip______________
                       Phone ______________________E-mail_________________________
                       Contact Person ________________________ Title_________________

                        In order for us to quote and shop your group coverage we need some very basic information.
                          Please give us the total number of employees that will be quoted in each class listed below

Total number of employee’s on Health plan               ____________
Census Information, we need the total number of employees covered in each category below
(e) Employee only total            ____________
(e s) employee spouse total        ____________
(e c) employee with child total    ____________
( f ) Family total                 ____________

Current Health Insurance provider ___________________
Type of plan - PPO, EPO, HMO or Traditional _________________

Do you also want a quote for - Dental ____________Vision_____________ Please mark with a yes or no in space provided.

We will be able to have a quote proposal for you within 24 hours for groups under 50.
We will search for the very best rate and coverage based on the information provided.

If possible a break down of your current plan would be a tremendous help. You can e-mail or fax it to us. Health quote request

Please contact Tom Maneen for any questions or additional information.
Thomas Maneen
Cell 315 867-4536
Fax 315 894-5277