Individual and Group Health Insurance Quote Form

Individual and Group Health Insurance Quote Form

Are you lookng for Individual or Group Health Insurance coverage information?
How many people do you estimate will be in the group you are looking to cover?
Once you complete this brief questionare, you will be sent a “Group Census Excel Spreadsheet” that you will need to complete, save and email back for submission. Once you have completed this preadsheet, your application will be submitted to underwrititing for finql ratuing and approval. You should receive the email with the spreadsheet within 24 hours. Please check spam folder.
I understand submission will be rejected if the USAHP Census does not include Full Name, Address, DOB, & Gender of each Employee & Dependent applying.
I understand adding or removing Employees from the Census after underwritten rates are produced will cause rates to change.
I understand to only list the Employees & Dependents on the Census who intend to enroll in coverage. DO NOT LIST WAIVERS (that is anyone who is declining coverage)
I understand Groups who are currently insured, who also provide existing plan Rates & Outlines will generally receive lower rates from underwriting.
Are you looking to cover 50 or more employees?
Is there currently a group plan in place?
I understand if the group is more than 50 Employees, existing Plan Outline & Rates are required for submission. Underwriters are not able to bid without.
I understand it can take up to 7 business days to receive Final Underwritten Rates.
Once you complete this brief questionare, you will be sent a “Group Specific Enrollment Link”. This link will be sent directly from underwritng within 2 busniess days. Once you complete the application, the underwriting process will begin.
Name of Owner
Name of Owner
First Name
Last Name
Company Address
Company Address
City
State/Province
Zip/Postal
Country
Name
Name
First Name
Last Name
Would you like our Ancillary Plans like Dental, Vision, Accident, etc. to be included on the Group Specific Enrollment link?
Address
Address
City
State/Province
Zip/Postal
Country

Health Questions

Does any of the following situations apply to anyone you are looking to cover?
Have you or anyone you are looking to cover had the following conditions?
Have you or anyone you are looking to cover been diagnosed with diabetes?
Does any of the following apply?
Have you or anyone you are looking to cover been treated or been advised by a physician to have treatment for the following conditions within the last two years?
For each person applying for coverage, have they seen a medical provider, had treatment recommended, received care (including prescriptions), or been hospitalized for any ofthe following within the last 5 years?