Company name:

Phone: (Area Code) 123-4567 + Ext 789   Best time to call

Contact Person    Healthy Florida Consultant

Email: Quote@HealthyFlorida.com

Address State Zip

Currently Insured Group . If yes Carrier Total full time employees(30hr+) Part Time

Renewal date             Note: 4 Full Time Employees Minimum to quote a group

Example       Male Female      Date of Birth      Type of coverage   Children to be Insured
______________________________________                                                                See notes E, E/C, E/S, F

Emp   1 Male Female        Date of Birth      Type of coverage   Children to be Insured

Emp   2 Male Female        Date of Birth      Type of coverage   Children to be Insured

Emp   3 Male Female        Date of Birth      Type of coverage   Children to be Insured

Emp   4 Male Female        Date of Birth      Type of coverage   Children to be Insured

Emp   5 Male Female        Date of Birth      Type of coverage   Children to be Insured

Emp  6  Male Female        Date of Birth      Type of coverage   Children to be Insured

Emp   7 Male Female        Date of Birth      Type of coverage   Children to be Insured

Emp  8  Male Female        Date of Birth      Type of coverage   Children to be Insured

Emp   9 Male Female        Date of Birth      Type of coverage   Children to be Insured

Emp 10 Male Female        Date of Birth      Type of coverage   Children to be Insured

Additional employees CLICK HERE

Notes -Type of coverage ; E = Employee, E/C = Employee + Children, E/S= Employee + Spouse, F = Family

Type comments here.