P.O. Box 33341
Washington, DC. 20033
Tel: (202)296-8614
Toll-free 1-800-964-8614
Fax: (202)296-6333
E-mail: info@paulbalep.com

Group Health Insurance Quotes Request Form

<<Independence is number one>>. We are nonexclusive producers who represent an average of eight companies-not just one. Paul Balep can evaluate and compare the products of several fine companies to find you the right combination of coverage and value.

Business Profile

To help our insurance representatives better understand your Group Health insurance needs, please complete the following form below and click the “Submit” button for a free, no-obligation quote. A PaulBalep representative will call you to set up a meeting to discuss your insurance and financial goals. Please provide the information for every eligible employee: name, residence address, date of birth, coverage type (employee - employee plus one - family). An eligible employee is an active, full-time employee who works at least 30 hours per week on a regular scheduled basis and is included on the employer's payroll for Social Security and Federal Income Tax Withholding, regardless of whether he/she is covered on a current Group Health Insurance Plan.

Privacy Notice: All information you provide is solely used for the purpose of providing you with quotes. We will never sell, give, or otherwise transfer your personal information to any person or entity other than the insurance companies, agents, and representatives selected. In some cases insurance companies we work with may request credit score.

Please enter the contact person's first and last name who will be responsible for processing the quotes:
What is the company's 5-digit Zip code? (No P.O. Boxes please)          
Will this insurance replace an existing business policy?   yes  no
What is the business operating status? Sole Proprietorship Corporation Limited Liability Corporation Partnership Other
Do you know your 4-Digit SIC Code? (5699 SIC Code Finder)        
Please provide a brief description of the business: 
About how many full-time employees? 
Part-time employees? 
Approximately what date did the business begin operating? 
What is the estimated average annual revenue of the business? 

Requested Group Health Insurance Coverages

What type of health insurance coverages are you interested in? HMO (Health Maintenance Organization) POS (Point-of-Service) PPO (Preferred Provider Organization) Not Sure

What is the total number of employees you wish to cover?

Please choose the preferred Co-pay amount

$5 $10 $15 $20 $25 Not Sure

What deductible amount do you want? $500 $1,000 $1,500 $5,000 $10,000 Not Sure
What optional coverages would you like? Prescriptions Dental Vision Care Wellness

Please provide any additional information you feel is pertinent to the insurance coverage you need:

Select all of the following coverages you would like agents to include in your group health insurance quote. Please you may visit us online at www.paulbalep.com . Click on any coverage term to see a definition.

Umbrella Liability (Excess) Commercial Auto
Business Owners Policy Business (Income) Interruption
Commercial Crime Commercial General Liability
Commercial Package Policy Directors' And Officers' Coverage
Employment Practices Liability Errors And Omissions
Technology Business Package Workers Compensation
Bonds Commercial Property
Please enter further information or questions about desired coverages:
Insurance Information
Please tell us more about your current or recent insurance policy. Be as accurate as possible.
Your most current insurance company? (You won't receive a quote from this company)
What date does your current policy expire/renew?
How long have you been insured with your current insurance company?
Years Months
Extremely important: How long have you been continuously insured?
Years Months
Contact Information
In most cases, the insurance companies we work with will send you your quotes via email. In some cases, when additional
information is needed, they will need to speak with you personally. Please provide valid contact information as requested below.
Company Name (DBA):
First Name: Last Name:
Street Address: Apt or Unit :
City: Country:
State: Zip Code:
Please enter a valid E-Mail address:
Business Telephone Number:
Contact Telephone Number: Ext:
Cell Telephone:
Fax Number:
Dollar amount of life insurance coverage desired: $
Type of coverage: Term life 10-15-20-30 Permanent whole life Universal life
If necessary, best time of day to contact you? Anytime Morning Afternoon Evening
How quickly do you need your request processed? Day(s)
Please provide any comments you have for the agents who respond to this quote request:

Where permitted by law, some insurance companies may confirm your information, through the use of consumer
reports, which may include credit score and driving record.
By submitting this information, I request that insurance companies subscribing to the PaulBalep quote service contact me with quotes via email, telephone and fax using the information I have provided.
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