Contact Us: (928) 214 8694
Home
About Us
Services
Home Owner's Insurance
Auto Insurance
Life Insurance
Health Insurance
Renters Insurance
General Liability & Property
Commercial Auto Insurance
Companies
Get a Quote
Home Owner's Quote
Auto Quote
Life Quote
Health Quote
Commercial Auto Quote
Group Health Quote
FAQs
Contact Us
Insuring
Your
Future
Request a Group Health Quote
* Mandatory Fields
General Information
Company/Business Name:
*
Business Address:
City:
State:
<-Select->
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Country:
United States
Phone:
Fax (Optional):
Contact Person Information
First Name:
*
Last Name:
Day Phone:
Night Phone:
Best Time To Call (HH:MM):
AM
PM
E-mail Address:
*
Business/Company Information
Total Number of Employees:
How Long Have You Been In Business?
Business Description:
What % Will Your Company Contribute Towards Group Insurance?
Are You Currently Insured?
Yes
No
Types of Health Insurance Plan:(Please choose the type of health insurance plan you intend to provide to your employees)
HMO (Managed care system with in-network regulations)
PPO (Permits out-of-network visits with higher co-pay or deductible)
POS (Point of service; most flexible managed care system)
Self Insured (Employees deposit premiums into company health insurance fund)
Not Sure (Please help us determine the best plan for our needs)
Additional Health Insurance Coverage(Optional):
Dental
Vision, Eye Care
Other Wellness Programs
None
Not Sure
Census
(Please complete the census below if 10 or fewer employees will be enrolled for group health insurance plan; if insurance is required for more than 10 employees, please refer the same in the Comments)
Count:
Sex:
Male
Female
Age:
Coverage:
United States
Zip Code:
Current Insurance Information
Insurance Company Name:
Policy Expiry Date (MM/DD/YYYY):
Any additional comments or information that might be helpful in your Group Health insurance quote:
Disclaimer
No coverage of any kind is bound or implied by submitting information via this online form.
•
We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
•
We will not distribute information to other parties other than for insurance underwriting purposes.
•
By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.
Yes,I Agree
Client Testimonials
Our Affiliations
Instant Health
Quote
Apply Now
Personal Insurance
Business Insurance
Client Services
Questions? Contact Us today!
Giese-Eden Insurance
1750 S Railroad Springs Blvd, Suite 6
Flagstaff, AZ 86001
Phone:
(928) 214 8694
Fax:
(928) 214 8697
E-mail:
info@geinsuranceagency.com
Instant Blue Cross/Blue Shield Quote
Click Here
for Free Quote
Home
About Us
Services
Companies
Get a Quote
FAQs
Contact Us
Copyright © 2008 Giese-Eden Insurance. All Rights Reserved.
Disclaimer
Website Design by
RiaEnjolie
