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	Ron Gambardella Insurance & Financial Services 800-685-5727

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Ron Gambardella

Independent Agency

Serving Families Since 1999

www.rongam.com

Employee Benefits - Group Health Request Form:

For additional Information please contact our agency today!

Quote Forms: Term Life Permanent Life Annuities Health LTC Group Health
Group Health, Dental, Life & Disability Quotes
Complete this quick & easy group health request form and one of our licensed insurance professionals will call you to review your companies insurance options. You may also call our agency direct at 800-685-572.
Company Information:
Legal Name of Business:
Contact Name:
Address:
City:	State: Zip:
Business Phone:	Fax:
Best Time To Call:	E-Mail:

Nature of Business:
Type of Business:
Standard Industry Code (if known):
# of Full Time Employees:
# of Part Time Employees:
Give a complete description of any hazardous or dangerous duties performed by your employees:

Current Group Health Benefits:
Carrier (Company) Name (not agency):
Please give a brief description of your current Group Health plan:

Benefits Desired:

Major Medical Deductible:

Optional Pregnancy Coverage:

yes
no

Dental Coverage:

yes
no

Supplemental Accident Coverage

yes
no

Disability Insurance:

yes
no

PCS Card:
(Prescription Discount Option)

yes
no

Group Life Insurance:

Amount:

yes
no

PPO Option

yes
no

HMO Option

yes
no

Please list all employees you wish to cover:

** You may also email your companies census in a text, delimited or excel file.

Employee Name

Date of Birth

Age

Sex

Dependent Status

Male
Female

Additional Comments

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 email an additional listing.

** You may also email your companies census in a text, delimited or excel file.

Please click on the "Submit" button to send your quote request.

Thank you for giving Our Agency the opportunity to provide you with a free, no-obligation group health insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. If you have any questions please contact our office between the hours of 9:00 a.m. and 5:00 p.m. (Eastern Standard Time) Telephone: 800-685-5727.

We highly recommend that once you receive your quote, you contact our office to review your quote and allow us to professionally provide you with an insurance needs analysis in person or over the phone

Investments offered through Jefferson Pilot Securities Corporation, Member SIPC to residents of CT 5 Forest Park Drive, Farmington, CT 06032, Phone: 800 678-7806