First Eagle Insurance: Health Insurance. GHIQ

FREE HEALTH INSURANCE QUOTE
FREE, NO OBLIGATION GROUP HEALTH INSURANCE QUOTE

GENERAL INFORMATION

TYPE OF BUSINESS

Type of Business:
Standard Industry Code:
Number of Full Time Empoyees:	Number of Part Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Health Insurance Information

Company Name (not agency):
Please give a brief description of your current Group Health plan:

BENEFITS DESIRED

Major Medical Deductible:		Optional Pregnancy Coverage:	yes no
Dental Coverage:	yes no	Supplemental Accident Coverage:	yes no
Disability Insurance:	yes no	PCS Card: (Prescription Discount Option)	yes no
Group Life Insurance:	yes no	PPO Option:	yes no
Amount:		HMO Option:	yes no

EMPLOYEE INFORMATION
(list all employees you wish to cover)

Employee Name	Date of Birth	Age	Sex	Dependent Status
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
Please use this box for comments or additional employees that you wish to cover.

Licensed in State of California.

LICENSE #: 0787078

Phone: (800) 316-3002
Fax: (818) 500-1855