REHA Quick Quote Request For Groups

Company Name

 # Employees
# Covered Employees
Address
 City
State
 Zip
Contact Name
Title
Phone
Fax
Type of Business
 SIC (if known)
 Years in Business
Current Health Insurance Carrier
 Name of Association (if applicable)
Current Medical Rates:
Employee Only

 Employee +Child
 Employee + Children
 Employee + Spouse
 Family
Current Product Type
(POS, PPO, HMO)
 Office Visit Copay
($5, $10, $15)
 Rx Copay
 Coinsurance Level
(100/80, 90/70, etc.)
Describe Employer Contribution Toward Employee Benefits (i.e. – employer pays 80% of premium, employer pays only single rate, etc.)

Name of Workers Compensation Carrier

Date of Next Rate Renewal
 Name of Current Broker (If applicable)
Number of Full-Time Employees Waiving Coverage
 Reason For Waiving Coverage
Are you aware of any significant health problems or ongoing medical conditions among any employees or family members (i.e. – diabetes, heart disease, cancer, chronic back problems, pregnancies, pending transplants, pending surgery, etc.)? If yes, please describe briefly.

Census (Please complete the following information. If you have more than 50 eligible employees, leave the census information blank. We will contact you for all necessary information.)

 

Eligible Employee
Name (optional)
Date of
Birth
Sex
Zip Code
of Residence
Employee
Only
Parent/
Child
Parent/
Children
Employee
+ Spouse
Family
1.
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4.
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50.
By submitting this census via email, I authorize the coalition to seek rate quotes on our behalf.
Name
Title