Company Name
Address
Email
Contact Name
Phone Number
Number of full-time employees
Fax Number
Nature of Business
Current Carrier & Plan
Renewal Date
Employer Contribution to Employee:					%
Towards Dependent Cov:					%
Please complete with all full-time eligible employees and fax to PrimeGroup at (888) 785-4311 .
Please indicate all lines of coverage interested in:   Health           Dental          Life
# Employee Name Gender Birthdate or Age Type of Coverage Zip Code 1 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 2 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 3 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 4 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 5 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 6 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 7 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 8 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 9 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 10 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 11 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 12 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 13 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 14 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 15 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 16 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 17 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 18 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 19 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 20 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 21 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 22 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 23 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 24 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family 25 Female Male Employee Only Employee & Spouse Employee & Child(ren) Employee & Family             Please note that quotes will take about 3 to 4 business days from date completed census is received (longer if out of state).