Dennis & Silvia Conger Insurance Agency: Group Quote

This is a secure form submitted over SSL.
Click here to access the form in its own window.

Thank you for your interest.

Quotes are for Minnesota and Western Wisconsin organizations only, and are not final rates (which are subject to underwriting).

We specialize in custom plan design.

Use this form to submit a small group medical insurance quote request (2-50 EEs).

Please contact us separately to request a quote for a large group (above 50 EEs) or for products other than medical insurance (i.e. dental, disability, etc.).

At the end of this form we will ask you to fax up to three items if applicable:

1) A COPY OF YOUR MOST RECENT HEALTH INSURANCE INVOICE;

2) CURRENT PLAN DESCRIPTION;

3) CENSUS SHOWING AGES OF ALL ELIGIBLE EMPLOYEES, THEIR SPOUSES AND DEPENDENTS - (fax; or can fill-in information in the CENSUS section below).

--------BEGIN FORM:

Please tell us why you are seeking a quote from our agency in particular

Organization Name *

Multiple Locations

Yes No

Headquarters *

Minnesota Wisconsin Other

Total # W-2 Employees *

Total # ELIGIBLE--Per Your Requirements--W-2 Employees *

# Years in Existence

Are You Self Insured or Fully Insured? *

Self Fully Don't Know Not Insured

Describe Briefly What Your Business Does *

SIC Code (if known)

Contact Name *

Contact Title *

Address1 *

Address2

City *

State *

Zip *

County *

Phone *

Fax

Email *

Confirm Email *

Web Address

Current Insurance Company *

Name of Current Plan

Major Ongoing Health Issues - if known *

Insurance Rating or Table by Current Carrier - if known

In MN ERs must fund at least 50% of EE health insurance premiums. The ER is not obligated to fund any portion of family member premiums.

% EE Prem to be Pd by ER *

% FAM Prem to be Pd by ER *

Would You Like to See Quotes for a Copay Plan? *

Yes No Don't Know n/a

Would You Like to See Quotes for a Consumer Directed Health Plan (CDHP)? *

Yes No Don't Know n/a

Notes (if any) about the above

Renewal Date of Existing *

Requested Effective Date of New (doesn't have to match renewal if switching carriers) *

Best days and times to meet (check all that apply):

No best days or times

Mon am

Mon pm

Tues am

Tues pm

Wed am

Wed pm

Thurs am

Thurs pm

Fri am

Fri pm

Best days and times notes (if any)

----------BEGINNING of CENSUS section-----------

COMPLETE THIS SECTION ONLY IF YOU ARE UNABLE TO PROVIDE A CENSUS. This pertains to ages of all eligible EEs, their spouses and dependents.

#EEs 0-18

#EEs 19-24

#EEs 25-29

#EEs 30-34

#EEs 35-39

#EEs 40-44

#EEs 45-49

#EEs 50-54

#EEs 55-59

#EEs 60-64

#EEs 65+

#Spouses 0-18

#Spouses 19-24

#Spouses 25-29

#Spouses 30-34

#Spouses 35-39

#Spouses 40-44

#Spouses 45-49

#Spouses 50-54

#Spouses 55-59

#Spouses 60-64

#Spouses 65+

#Dependent Children through age 18

#Dependent Children age 19 through 25

Total # EE + Spouse only

Total # EE + Spouse + Dependent Children

Total # EE + Dependent Children only

Census notes (if any)

----------END of CENSUS section-----------

Insurance Company Preference?

Besides reigning-in premium costs, what is most important that you wish to achieve with a new group plan?

Additional Notes (if any)

Would you like a copy of the information submitted by you on this form to be emailed to you? *

Yes No

After submitting form, please fax the applicable items (up to three) mentioned at the top of this form (and cover sheet with your contact information) as follows: 1) COPY OF MOST RECENT HEALTH INSURANCE INVOICE (if group currently insured); 2) CURRENT PLAN DESCRIPTION (if group currently insured); 3) CENSUS - If didn't complete CENSUS section above.

Fax to 651-275-1933. ATTN: Web Quote.

****AFTER RECEIVING your submission and fax, we will confirm receipt and contact you with any questions and to arrange a meeting to discuss the quote.****

****QUOTES ARE NOT final rates (which are subject to underwriting).****

****PLEASE CALL US at 651-275-1474 if you have not heard from us within two business days.****

****WE APPRECIATE YOUR TIME in completing this form. Please be patient: the submission process may take a minute.****

Form is completed to my satisfaction *

Yes No

( * Required Field )