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

GROUP HEALTH (Dental,Life,Disabilty) INSURANCE QUOTE	If you do not have the time to fill in the form below, but would like more information or would like someone to call you concerning group health insurance for your company........ just click here to send a quick note to Group Health Plans of Louisiana All information is kept confidential and will be used for quote purposes only. We do not resell information to anyone for any purpose. Questions...info@ghpla.com
Group Health Plans of Louisiana ............ located in the "Big Easy", in New Orleans, La. 1-888-456-1858/504-456-1858 or Send us an E-mail
Please fill in as much data as possible below:
General Information * = denotes a required entry
*Legal Name of Business:
*Contact Name & Title:
Address:
*City:	State: *Zip:
*Business Phone:	Fax: ex 555-555-5000
*Contact Email Address:	(Required)

* # Full Time Employees:

Insurance Company Now:


Benefits Desired
HMO Option:	yes no	Consumer Directed Health Option:	yes no	Dental Insurance yes no
Choose your Deductible:	If Desired	Medical Savings Acct. Option:	yes no	Group Life Insurance yes no Amount Desired: $

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 your employees email sales@ghpla.com or reload and resubmit this form with the other employees listed. Call 1 888-456-1858 or 504-456-1858 with problems.

Additional Comments ----AND---- Known Health Conditions

Health conditions:
Please list below: known health conditions such as: heart trouble, cancer, lung, liver, hepatitis, aids, diabetes, alcohol & drug; mental & nervous, etc.
Please include...... diagnosis, dates, & treatments. Age, sex, condition, only. No Names, please.
Your privacy is guaranteed by law. Information disclosed below is protected and will be used is for rating purposes only.

* How did you find us--which search engine?>

Verification Code:

Please click on the "Submit Quote" button to send your quote request.

(only click once, it may take 2-5 seconds)