To request a quote for your group, please complete the questions below and then hit the submit button. Your group quote request form will be sent by e-mail to Flippo Insurance and Employee Benefits. You must include your address, phone number and e-mail address in case we have questions about your quote request. If you have an employee census, you can copy and paste it into the Insert Census box. Or you can download our Group Census Form here and complete it and insert it in the Insert Census Form Box below or Fax it to 866-263-4768.

Group Quote Request Form

Group Quote Request Form

Company Information

Company Name

Your Name

Your Title

Company Address

Address

City

State

Zip Code

Phone

Fax

E-mail

Group Questionnaire: Please complete the following questionnaire.

Total number of employees including part time

Current group health insurance carrier

Nature of your business

SIC Code

Requested Plan Benefits:

Check all of the plan benefits listed below you would like included in your group health quote.                                 

Optional Benefits:

Select any optional benefits listed below that you would like to include in your quote request.

Current or Renewal Rates:

Indicate below your current or renewal rates for your current group health plan.

Employee Only

Employee + Spouse

Employee + Child(ren)

Family

Total Monthly Premium

# Enrolled

# Enrolled

# Enrolled

# Enrolled

Total Enrolled

Insert Census Here:

Cut and Paste your completed census form in the box below or type in your group census information in the form below.  Or click here for Group Census Form to complete and insert or Fax to 866-263-4768.

Census Form:

Type in your group census information in the form below

Date of Birth

Age

Zip Code

Coverage Tier

EE = Employee Only

ES = Employee + Spouse

EC = Employee + Child(ren)

Fam = Family

If you have more than 10 employees, use the Group Census Form to complete and insert above or Fax to 866-263-4768.

Health Conditions:

List any health conditions below that you are aware of in your group. Do not list employee’s name. Just list health condition and whether it is an employee or dependent. List any medications taken for condition and general prognosis.

Health Condition

Employee or Dependent

Medications Taking

General Prognosis

Total Monthly Premium:

If you don’t know the premiums by tier or if you have an age-rated premium, indicate your total monthly premium below and the total number enrolled.