Woxland Health Insurance: Request a Quote for Group Benefits

Company Information
*Required Fields
	*Company Name:
	*First Name:
	*Last Name:
	*Address:
	*City:
	State:	WASHINGTON
	*Zip Code:
	*Work Phone:
	Alternate Phone:
	*Best time to contact:
	*E-mail
	Type of Company?
	Do you currently have Business Group Health?	No Yes
	If yes, when does it renew?
	Name of current carrier
	Description of Business:
	Number of Locations:
	*Number of Employees:
	Number of Employees currently covered:
Current Plan Information
	Type of Health Plan:
	Current Deductible:	Other:
	Current Co-Insurance Percentage:	Other:
	Office Visit Co-pay?	No Yes	If yes, co-pay amount
	Prescription Drug (RX) Co-pay?	No Yes	If yes, co-pay amount
	Dental Plan in place?	No Yes	Want Dental?	Yes No
	Vision Plan in place?	No Yes	Want Vision?	Yes No
	Section 125, Cafeteria or Premium Only Plan in place?	No Yes
	*Voluntary Benefits (employee paid) in place?	No Yes	Want Voluntary Benefits?	Yes No
	Employer Contribution Percentage for Employees?			Other:
	Employer Contribution Percentage for Employee Dependants?			Other:
	Additional Comments or Questions?



Thank you for your inquiry!