Group Health Insurance Questionnaire
Please Answer All questions
Company Name:
Contact Name
Street Address:
City/State/Zip:
Mailing Address:
City/State/Zip:
Phone No:
Fax No:
Type of Business:
Anniversary Date of Health Plan:
Present Health Insurance Carrier:
Number of Full-time Employees:
Number of Part-time Employees:
Name of Work Comp Carrier:
Renewal Date:
Are the Owners/Officers covered under the Work Comp?: YesNo
What benefits would you like to see quoted
Health: Yes No
Dental: Yes No
Vision: Yes No
Life: Yes No
Disability: Yes No
Work Comp: Yes No
401K: Yes No
Commercial Liability: Yes No
Are there any particular companies you would/would not like to see quoted?:
To the best of your knowledge, please list below any known major medical conditions, anticipated surgeries or pregnancies:
1.
2.
3.
4.
Your Email Address:
Please note, once you submit this application and it is received by The Lynn Company, you will be contacted for further information including a Census of Employees.