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Employer
Health Insurance Quote
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For
TN Based Companies Only
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Census
Information Form--Request for Insurance Proposal
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Does
the Company Currently Have Insurance?
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Yes
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No
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Yes
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No
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If
any employee or dependent (including cobra) bas been
diagnosed or treated or had any recommendation for treatment
for any of the following please indicate with a yes.
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HIV
positive, AIDS, or other immune system disorder?
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Yes
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No
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Kidney
or Liver disorder (excluding kidney stones)?
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Yes
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No
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Yes
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No
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Heart
attack, congestive heart failure, or serious hearing
disorder?
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Yes
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No
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Nervous
and mental disorder or disabilities requiring hospitalization?
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Yes
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No
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Alcohol
or drug abuse treatment within the last 5 years?
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Yes
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No
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Emphysema
or Tuberculosis?
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Yes
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No
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Asthma
Hospitalization within the last 3 years?
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Yes
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No
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Diabetes
requiring prescription medication?
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Yes
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No
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Diabetes--diet
controlled and NOT
requiring medication?
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Yes
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No
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Maternity
(currently pregnant)
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Yes
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No
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Male
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Female
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Male
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Female
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Male
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Female
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Male
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Female
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Male
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Female
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Male
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Female
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Male
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Female
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Male
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Female
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Male
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Female
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Male
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Female
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Male
|
|
Female
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Male
|
|
Female
|
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Quote High Deductible Health Plans that are
Health Savings Account (HSA) qualified?
Yes
No |
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**
If your company has more than 12 employees complete
this form and submit it as many times as necessary.
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