Profit Sharing Profit Sharing Profit Sharing General InformationCompany*Full Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Type of BussinessType of BusinessNo. of Full Time EmployeesNo. of Part Time EmployeesGive a complete description of any type of hazardous/dangerous duties performed by your employeesCurrent Group Health Insurance InformationCarrier / Company Name (Not Agency)Policy Expiration Date: Date Format: MM slash DD slash YYYY Premium Amt ($):Years Insured:Please give a brief description of your current Group Health Plan.Benefits DesiredMajor Medical Deductible$200$250$300$500$1000Dental CoverageYesNoDisability InsuranceYesNoSupplemental Accident CoverageYesNoGroup Life InsuranceYesNoPPO OptionYesNoHMO OptionYesNoAmount ($)Employee InformationPlease list all participating employees you wish to coverName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeZip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyIf you were not able to list all employees you wish to cover in the spaces above, please add them below or indicate that you will fax or e-mail an additional listingFinal Questions/CommentsComments / Remarks
