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:  

Verify Code

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

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