This form will be sent through email and is not completely secure. If you are not totally comfortable with the e-mail system then you may obtain a Downloadable Version of this form and fax it to (801) 579-9911.

As an independent agent we can quote many companies like Altius, Blue Cross Blue Shield, IHC, Pacific Life, Starmark, United Health Care and more. We will help you find the best cost effective plan for your company to fit your needs.

Business Name:
Address:
City/State/Zip:
Phone: Fax:
Do you currently have a group plan? Yes No
Name of Carrier:
Deductible: CO-Pay RX
EE = Single Employee   ES = Employee & Spouse   EC = Employee & Children Only   FF = Full Family
 
Employee Name
Age
Sex
EE
ES
EC
FF
Age of Spouse
# of Children
1
Male
Female
2
Male
Female
3
Male
Female
4
Male
Female
5
Male
Female
6
Male
Female
7
Male
Female
8
Male
Female
9
Male
Female
10
Male
Female
11
Male
Female
12
Male
Female
13
Male
Female
14
Male
Female
15
Male
Female

Revised:February 23, 2010-- This website is for comparison and informational purposes only. Actual premiums and coverage availability may vary due to age, sex, family size, zip code, health history, and tobacco use and are subject to change at any time without notice. All information submitted is held in strict confidence. See policies and brochures for coverages, exclusions, restrictions, and limitations. For any Questions, Quotes, Concerns, or Problems with this Website Please Contact Us Anyone can quote you a low premium and tell you how wonderful the plan will be. Remember it costs nothing more to have an agent. The insurance companies pay me directly , and do not charge you more for usng an agent. Therefore, I am a free source for questions and concerns. If you have learned more from me than the competition, I hope you will let me be your agent.