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Health Insurance Quotation Template

This document is a data sheet to obtain quotes for group health insurance. It requests company information, the number of employees to be covered, and medical details for each individual to provide accurate quotes. Personal information such as name, date of birth, current medications, and coverage needs are collected for up to 25 employees.

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Prem Kapoor
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2K views1 page

Health Insurance Quotation Template

This document is a data sheet to obtain quotes for group health insurance. It requests company information, the number of employees to be covered, and medical details for each individual to provide accurate quotes. Personal information such as name, date of birth, current medications, and coverage needs are collected for up to 25 employees.

Uploaded by

Prem Kapoor
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Group Health Insurance - Census Data Sheet: This form is used to collect employee data for processing group health insurance, including personal information and coverage needs.

Group Health Insurance - Census Data Sheet

This information will be used to obtain quotes for group health insurance coverage.
To get an accurate quote please furnish all requested information and list any known medical
conditions or medications taken by anyone to be included on the insurance plan.
Company Name
Address Steve Dixon
City, State, Zip Phone Number (972) 355-8132
Phone Number ( ) Fax Number (972) 692-7192
Steve@HealthPlanFinders.com
Nature of business
Requested Effective Date S.I.C. Contact Person:
Total # of Full-time Employees
# of Employees to be on plan Current Insurance Company _
# of out-of-state employees to be covered Current Deductible

Employee Name Sex Date of Birth Spouse DOB # of Coverage* Home Zip
(If to be covered) children (see box below) Code
(if to be covered)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Use separate sheet if needed

Coverage* Needed Medical Conditions (indicate employee #)


E = Employee Only
ES = Employee & Spouse Only
EC = Employee & Child(ren) Only
FF = Full Family Coverage

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