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General Information
Agency name:
Agent name:
Business name:
Street address:
Zip code:
Phone:
Fax:
I would like to request a quote for:
Health
Dental
Plan Design
Current Plan
Desired Plan
Insurance provider:
Aetna
AmeriHealth
Horizon BCBSNJ
Oxford
Other:
Aetna
AmeriHealth
Horizon BCBSNJ
Oxford
Plan type:
None
HMO
PPO
POS
Open Access
Other
HMO
PPO
POS
Open Access
Office co-payment:
None
$5
$10
$15
$20
$30
Other
None
$5
$10
$15
$20
$30
Other
Deductible:
None
$250
$500
$1000
Other
None
$250
$500
$1000
Other
Co-Insurance:
None
100/80
100/70
100/90/70
Other
None
100/80
100/70
100/90/70
Other
Prescription (Rx):
None
$5/$10
$10/$15
$15
Other
None
$5/$10
$10/$15
$15
Other
Comments:
Company Census
Employee Name
Gender
Status
Birth Date
1:
Male
Female
Single
Husband/Wife
Parent/Child
Family
Waived
2:
Male
Female
Single
Husband/Wife
Parent/Child
Family
Waived
3:
Male
Female
Single
Husband/Wife
Parent/Child
Family
Waived
4:
Male
Female
Single
Husband/Wife
Parent/Child
Family
Waived
5:
Male
Female
Single
Husband/Wife
Parent/Child
Family
Waived
