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* Company Name
* Name of primary contact
* Phone
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How did you hear about us?
Is there a health plan inforce? yes   no
Dental? yes   no
Additional Members:
Sex Name Birth date Status
Status Codes: EE only = single employee with no dependents
EE + Spouse = married employee with no children
EE + Child = single employee with one child
EE + Family = employee with 2 or more dependents
Anniversary dates?
Why are you interested in looking at plans right now?
      Price? yes   no
      Plan design? yes   no
      Employee retention? yes   no
      Want to add new benefit(s)? yes   no
      Are there any current
medical conditions?
yes   no
      Please describe known medical conditions:
Proposed effective date?