Atlanta, Georgia
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Group Medical / Health Insurance Quote Request

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

InsureUSA is currently serving customers throughout metro Atlanta, and in the states of Georgia, Alabama, Florida, North Carolina and Tennessee. If your business is not located in one these states, we will not be able to provide you with personal or commercial insurance coverage, or provide you with an online quote.

* Required fields.

General Information
Legal Name of Business: * *
Contact Name: * *
Address: * *
City: * *
State: * *    Zip: * *
Phone: * *  Fax:
Best Time To Call:   AM   PM
E-mail Address: * *Invalid format.

About Your Business
Type of Business:
Federal Tax ID Number:
No. of Full Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Health Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:  
Premium Amount: $
Years Insured:
Please give a brief description of your current Group Health plan:

Benefits Desired
Major Medical
Deductible: 		Dental Coverage: Yes
No
Disability Insurance: Yes
No		 Supplemental
Accident Coverage: 		Yes
No
Group Life Insurance:
 Yes
No		 PPO Option: Yes
No
Amount: $ HMO Option: Yes
No

Employee Information
Please list all employees you wish to cover:
Employee Name Date of Birth Sex Dependent Status
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or e-mail an additional listing.


Additional Comments or Questions


Please click the "Submit Quote Request" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.