Group Health Plans of La. -- Group Health Quote Form


GROUP Life or Health INSURANCE QUOTE		We provide you with a free, no-obligation group health insurance quote. A copy of your current billing & current census (see below) will enable us to produce the most accurate quote possible for you. This information is kept confidential and will be used for quote purposes only. Questions...info@lalifeins.com
Out of Area, Phone 1-888-456-1858 , or (504) 456-1858 or Fax (504) 885-4640 or..........Send E-mail Louisiana Life Insurance.com located in the "Big Easy", in New Orleans, La. 1-888-456-1858

General Information
Legal Name of Business:
Contact Name:
Address:
City:	State: Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
Contact Email Address:

Type of Business
Type of Business:
Standard Industry Code (if known):
# of Full Time Employees:	# of Part Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Life or Health Insurance Information

Carrier (Company) Name (not agency):

What part of the premium will the company pay? for the individual, and/or for the family cost:

Please give a brief description of your current Group Life or Health plan:

Benefits Desired
        Group Health                  Group Life & Disability

HMO Option: yes  no Disability Insurance: yes  no

PPO Major Med. Deductible: Cafeteria Plan: yes  no

Dental Coverage: yes  no Group Life Insurance:

Amount: yes  no
$

Employee Information

Please list all employees you wish to cover:

Employee Name Date of Birth Age Sex Dependent Status

Male
Female

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Male
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Male
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Male
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Male
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Male
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If you were not able to list all of the employees you wish to cover in the spaces above, please "submit" these now,........ then reload this form blank to send the remainder. You may also use the Additional Comments section below or indicate that you will fax or email an additional listing.

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you wish a layered , or compensation based group or voluntary life, disability, health plan, please describe it here.

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Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

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Current Group Life or Health Insurance Information
Carrier (Company) Name (not agency):
What part of the premium will the company pay? for the individual, and/or for the family cost:
Please give a brief description of your current Group Life or Health plan:

Benefits Desired Group Health Group Life & Disability
HMO Option:	yes no	Disability Insurance:	yes no
PPO Major Med. Deductible:		Cafeteria Plan:	yes no
Dental Coverage:	yes no	Group Life Insurance: Amount:	yes no $

Employee Information
Please list all employees you wish to cover:
Employee Name	Date of Birth	Age	Sex	Dependent Status
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female


If you were not able to list all of the employees you wish to cover in the spaces above, please "submit" these now,........ then reload this form blank to send the remainder. You may also use the Additional Comments section below or indicate that you will fax or email an additional listing.