United Agencies inc

Hing & Associates Insurance Brokers Inc.

Call Us Toll Free: (800) 554-2330

Employee Benefits Form:

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 Health Insurance Information
Carrier (Company) Name (not agency):
Please give a brief description of your current Group Health plan:

Benefits Desired

Major Medical Deductible:

Optional Pregnancy Coverage:

	yes
	no

Dental Coverage:

yes

Supplemental Accident Coverage:

	yes
	no

Disability Insurance:

yes

PCS Card:
(Prescription Discount Option)

	yes
	no

Group Life Insurance:

Amount:

yes

PPO Option:

	yes
	no

HMO Option:

	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
If you were not able to list all employees you wish to cover in the spaces above, please 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 have additional information where there was not enough space, please enter them here.

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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