Group Health Insurance Quote

Company Name:
Contact person:
Title:
City:
County:
State:
Zip code:
Nature of business:
Phone #:	() - Ext
Best time to contact:
Fax #:	() -
Email address:
Number of full-time employees:

If you have 1-20 employees, please complete the census below.
If you have more than twenty employees, please skip to the end.

	Employee's Name	Age or DOB	Sex	Family coverage**	Spouse age or DOB	Cobra?	EE Home County or Zip code
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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18
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20

**Note:
EE = Employee only
E&S = Employee and Spouse
E&C = Employee and Children
E&F = Employee and Family
Comments or questions:

Health Insurance Home Page

Member of the ComeVisit Network

Licensed in:
Arizona, California, Texas, and Virginia. For other states, inquiries are referred on to agents licensed to handle insurance in that particular state.

PGA Financial has no intent to generate interest in any particular life insurance company or specific policy, but rather to inform and educate you on the general concept -- after which, if you are interested, a broker at PGA Financial will be glad to research companies that offer such plans, get you a quote and assist you in making a choice. If you do become interested and obtain a policy, the broker would be compensated by the insurance company.