Group Health

COMPANY INFORMATION

Fields marked (*) are mandatory

COMPANY NAME

YOUR FIRST NAME

YOUR LAST NAME

E-MAIL ADDRESS

STREET ADDRESS

CITY

STATE

ZIP CODE

DAYTIME PHONE

EVENING PHONE

FAX

BUSINESS TYPE

CURRENT GROUP HEALTH INSURANCE PROVIDER

EXPIRATION DATE OF CURRENT POLICY (IF APPLICABLE)

DESCRIPTION OF YOUR BUSINESS OPERATIONS

NUMBER OF EMPLOYEES

PLAN TYPE DESIRED

ADDITIONAL INFORMATION

BEST TIME TO CONTACT YOU

ADDITIONAL QUESTIONS OR COMMENTS

Great Northern Insurance Agency
Our Dedication Ensures Your Satisfaction