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Blackwell Insurance Agency

Quote Request Form for Group Health

 

To receive a group health quote that best suits your needs, please fill out and submit this form. Thank you.

Company/Client Name:
Address
City: State: Zip:
County of Residence:
Telephone: Fax:
Email:

Requested effective date:
Current carrier:
SIC code or nature of business:

Type of Coverage: S=Single, EC=Emp/Children, ES=Emp/Spouse, F=Family

AGE   GENDER   TYPE*   HEALTH CONDITIONS  
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       

 

Comments:

Carriers to be quoted:

 Anthem
 Bluegrass
CHA
Humana
UHC
Adenta-Delta
Other:

To submit your entry, be sure all fields are properly completed and then use the submit button:

 

 

 
 
   
Blackwell Insurance Agency
 502-231-7409 / email: blackwellagency@insightbb.com / FAX:502-231-7412
 
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