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Low cost Indiana, Michigan, and Ohio homeowners insurance quotes from Shuttleworth Insurance.com
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    Group Health Insurance
    Quotation Form
    One Simple Form - takes only 2-3 Minutes!


    Your Personal/Group Data:
     
    Your Name:
    Your Business Name:
    Street Address:
    City:
    State:
    Zip Code:
    E-Mail (REQUIRED):
    E-Mail again for accuracy:
    Phone:
    Fax (optional):
     
    (If more than 5 in group, contact us at: 800-432-3769 )

    Please Check the Group Products your company wants
    to make available to your employees:

    Group Health   Group Dental   Group Vision
    Group Life   Employee Benefits

    Group Underwriting Information:

    Employee #1 Name

    M/F

    Age

    Status

     

     

     

     

    Occupation

    Status

    Currently Insured?

    Plan type

     

     

     

    Employee #2 Name

    M/F

    Age

    Status

     

     

     

     

    Occupation

    Salary

    Currently Insured?

    Plan type

     

     

     

    Employee #3 Name

    M/F

    Age

    Status

     

     

     

     

    Occupation

    Salary

    Currently Insured?

    Plan type

     

     

     

    Employee #4 Name

    M/F

    Age

    Status

     

     

     

     

    Occupation

    Salary

    Currently Insured?

    Plan type

     

     

     

    Employee #5 Name

    M/F

    Age

    Status

     

     

     

     

    Occupation

    Salary

    Currently Insured?

    Plan type

     

     

     

     
    Currently Insured?
    (If yes, list carrier, and # of years
    continuous. If none, type N/C)
     
    Employee Health Problems?
    (Do any of your employees have special health problems or insurance needs? If no, write "none".)
     
    Group Plan Needs?
    (Tell us what features you want in your group plan so that we may get the coverage and benefits you are looking for!)


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    Thank you for filling out this form COMPLETELY!

    We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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