We feature a full line of Health Care Plans including Major Medical Plans, HMO Plans, Dental Insurance & Short & Long Term Disability Income from Companies such as Blue Cross & Blue Shield of MN, Health Partners, MEDICA, Fortis
Small Group Health Care Rate Quote Request Form
This is a request for a quote, not a policy application. Submitting this form does not obligate you to purchase any products. Please complete this form as accurately as possible. Insurance rates are subject to change.
Please complete and submit the following short form to have a Minnesota Health Insurance representative contact you, or click here to complete the long form.
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| Name:* |
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| Company Name:* |
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| Address:* |
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| City:* |
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| State:* |
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| Zip/Postal Code:* |
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| Email:* |
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| Telephone:* |
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| Fax: |
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General Information
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| Total number of Employees |
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| Number of Employees working more than 20 hours/week |
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| Employees working more than 20 hours waiving coverage |
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| More than 49 Employees in the previous calendar year? |
Yes
No |
| Number of Employees participating |
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| Number of Employees employed in Minnesota |
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| *Percentage Employer contributes toward Employee Cost |
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| Current Health Care Carrier |
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| Renewal Date |
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| *Most Small group plans require 50% employer contribution. |
Preferences
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| Coverage type? |
Major Medical 80/20 with deductible |
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250
500
1000 deductible |
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Co-payment (High Coverage
Option) |
| Dental Coverage? |
Yes
No |
Companies Plans Requesting Information On
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| MEDICA |
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| HealthPartners |
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| BlueCross BlueShield of MN |
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Employee Census
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| (The Employee Name is optional, Sex and Employee Date of Birth (DOB) are
mandatory, Spouse's DOB must be included if requesting coverage, Children's ages must be
included if requesting coverage and should be separated by commas |
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Please comment on any employees over 65 and not on Medicare.
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| Additional Comments |
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