Small Group Health Information Request

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Group Benefits Information Request

We feature a full line of Health Care Plans including Major Medical Plans, HMO Plans, Dental Insurance & Short & Long Term Disability Income from Companies such as BlueCross & BlueShield of MN, Health Partners, Medica, Assurant, Unum, and Colonial.

Group Benefits Rate Quote Request Form

This is a request for a quote, not a policy application. Submitting this form does not obligate you to purchase any products. Please complete this form as accurately as possible. Insurance rates are subject to change.

Please complete and submit the following short form to have a Minnesota Health Insurance representative contact you, or click here to complete the long form.

Name:*

Company Name:*

Address:*

City:*

State:*

Zip/Postal Code:*

Email:*

Telephone:*

Fax:

General Information

Total number of Employees

Number of Employees working more than 20 hours/week

Employees working more than 20 hours waiving coverage

More than 49 Employees in the previous calendar year?

Yes No

Number of Employees participating

Number of Employees employed in Minnesota

*Percentage Employer contributes toward Employee Cost

Current Health Care Carrier

Renewal Date

*Most Small group plans require 50% employer contribution.

Preferences

Coverage type?

Major Medical 80/20 with deductible

250 500 1000 deductible

Co-payment (High Coverage Option)

Dental Coverage?

Yes No

Companies Plans Requesting Information On

MEDICA

HealthPartners

BlueCross BlueShield of MN

Employee Census

(The Employee Name is optional, Sex and Employee Date of Birth (DOB) are mandatory, Spouse's DOB must be included if requesting coverage, Children's ages must be included if requesting coverage and should be separated by commas

	Employee Name	Employee DOB	Spouse DOB	Dependent Children Ages
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	Employee Name	Employee DOB	Spouse DOB	Dependent Children Ages
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Please comment on any employees over 65 and not on Medicare.

Additional Comments

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