Friday Jul 25, 2008

Group Health Insurance Coverage Quote

*How did you discover us?
*Company Name:
Address:
City:
State:
*Zip Code:
*Contact Person:
Title:
*Phone:
Fax:
*E-mail:
Current Insurer (if applicable):
*What type(s) of quote(s)
would you like?		 Health
Dental
Vision
Life
Disability
Pension Plans
Other
Do you currently utilize a
broker or consultant?		 Yes No
How many employees to insure?
*Do you have employees
in other locations?		 Yes* No
*If Yes, where?

*Please enter a census of all current, full-time employees.
Be sure to include EACH EMPLOYEE'S age and dependent status.

  • EE = Employee ONLY
  • ES = Employee + Spouse
  • EC = Employee + Child(ren)
  • F = Entire Family
Name (or Sex),  Age,  Family Status (EE, ES, EC, or F)

Please verify the accuracy of the information you have provided before submitting. Thank You! A broker will contact you as soon as possible.

Colorado Agency License #RPA00045298
Securities offered through Colorado Financial Services Corp (Member FINRA, SIPC)
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Group Insurance Analysts, Inc.
9306 West 58th Avenue
Arvada, Colorado  80002
Phone: 303-423-0162 ~ Toll Free: 888-423-3232
FAX: 303-423-5417 ~ Email: info@e-gia.com
~ In the Denver Metro Area ~