Employer
Health Insurance Quote
For
TN Based Companies Only
Census
Information Form--Request for Insurance Proposal
Does
the Company Currently Have Insurance?
Yes
No
Use Pull Down
$5,000.00
$2,500.00
$2,000.00
$1,500.00
$1000
$750.00
HDHP/HSA $1700
HDHP/HSA $2500
Other Amount
Unknown
Yes
No
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.
HIV
positive, AIDS, or other immune system disorder?
Yes
No
Kidney
or Liver disorder (excluding kidney stones)?
Yes
No
Yes
No
Heart
attack, congestive heart failure, or serious hearing
disorder?
Yes
No
Nervous
and mental disorder or disabilities requiring hospitalization?
Yes
No
Alcohol
or drug abuse treatment within the last 5 years?
Yes
No
Emphysema
or Tuberculosis?
Yes
No
Asthma
Hospitalization within the last 3 years?
Yes
No
Diabetes
requiring prescription medication?
Yes
No
Diabetes--diet
controlled and NOT
requiring medication?
Yes
No
Maternity
(currently pregnant)
Yes
No
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Male
Female
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee,
Spouse, & Child(ren)
Quote High Deductible Health Plans that are
Health Savings Account (HSA) qualified?
**
If your company has more than 12 employees complete
this form and submit it as many times as necessary.
