Minnesota MN Employee Benefits Group Insurance Health Life Dental Disability Blue Cross Blue Shield, Medica, HealthPartners HSA Critical Illness. Income

Revised:

May 06, 2015

763-535-7293

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	Quote Form Pages

We feature a full line of Health Care Insurance Plans including Major Medical Plans, HMO Plans, Critical Illness, HSA Plans, Cafeteria Plans, Dental Insurance & Short & Long Term Disability Income from Companies such as Delta Dental, Assurant Heath, HealthPartners, MEDICA & MetLife.

Small Group Health Care Rate Quote Request Form

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

Name
Company Name
Street
City, State ZIP
County Located
E-mail
Phone
Fax

General Information on Your Employees

Total Number of Employees	Number working more than 20 hours/week	Number working more than 20 hours/week waiving coverage

Number of Employees participating	Number employed in Minnesota	More than 49 employees in the previous calendar year?
		Yes No

General Information on Employer

Percentage Employer contributes toward Employee Cost	Current Health Care Carrier	Renewal Date

Companies Plans Requesting Information On

Blue Cross and Blue Shield of Minnesota
Blue Plus of Minnesota
Health Partners
MEDICA
Assurant Health

Additional Benefits

Life Insurance	Yes No
Short Term Disability Insurance	Yes No
Long Term Disability Insurance	Yes No
Critical Illness Insurance	Yes No
Health Savings Account (HSA)	Yes No
Dental Insurance	Yes No
If yes, do you have Dental Insurance now	Yes No

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, Monthly Salary is needed if requesting Disability Benefits).

	Employee Name	Sex M/F	Employee DOB	Spouse DOB	Dependent Children Ages	Monthly Salary
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	Employee Name	Sex M/F	Employee DOB	Spouse DOB	Dependent Children Ages	Monthly Salary
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	Employee Name	Sex M/F	Employee DOB	Spouse DOB	Dependent Children Ages	Monthly Salary
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	Employee Name	Sex M/F	Employee DOB	Spouse DOB	Dependent Children Ages	Monthly Salary
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	Employee Name	Sex M/F	Employee DOB	Spouse DOB	Dependent Children Ages	Monthly Salary
41.
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47.
48.
49.

Please comment on any employees over 65 and not on Medicare.

Additional Comments


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