Group Health Insurance Form - Henry Insurance Service

Date

Contact Name*

First Last

Contact Phone Number*

Group

Referred By

Current Carrier

Nature of Business or SIC Code

Include Disability?

Yes
No

Include Dental?

Yes
No

Include Vision?

Yes
No

Include Life Quote?

Yes
No

Life Insurance Amount

Contact Phone Numbers

Active Employees

Please list all active employees, if they will be including spouse or dependent children please entre under "name" spouse, son or daughter and give the date of birth. An employee may use your business zip code for residence zip code. Note: If an employee is not participating please give an explanation: Part Time (PT), Insured With Spouse (IWS), Own Individual Policy (OWN), Other Health Program (OHP), Ineligible or Declined.

Health Insurance Category:
EE Only - Employee Enrollment Only EE+Spouse - Employee and Child or Children EE+Dependent -- Employee and Child or Children Family - Employee, Spouse and Child or Children

If life benefit is included, please list those who qualify for life benefit but are not enrolling in the health plan.

Life Insurance Category for those not enrolling in Health Benefit: Life EE Only; Life EE+Spouse, Life EE+Dependents; Life Family

List of Active Employees

On each line, include:

Name, Sex, DOB, Category, # Dependent Children, Hire Date, Resident Zip Code

Known Medical Conditions

Without disclosing names, please list any known medical conditions in groub and how long condition has existed.

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