Small Business Information

Group Health Insurance Quote

We will research health insurance plan options and rates for your small business upon receipt of this information. If you have scheduled an appointment to discuss these quotes please submit this information at least 3 business days before our scheduled appointment. If you still need to schedule an appointment to review the quotes click here.

Question Title

* 1. Business Name

Primary Contact:

Primary Phone Number:

Primary Email:

Business Address:

City

Zip Code

Do you have employees outside of Michigan that will need coverage?

When do you need coverage to start?

Who is your group plan through now?

Do you want to offer additional benefits such as life insurance, dental, vision or disability benefits to the employees?

Do you want to offer a retirement savings plan or 401K to your employees?

Do you want to offer a Health Savings Account, Flex Spending or Health Reimbursement Account to employees?

How much of the premium, if any, will the employer contribute toward the employee monthly health insurance premium?

Other concerns or considerations we should consider when researching health insurance rates and options?

Question Title

* 2. Employee Census - email an employee census or manually enter them on this survey form.

I will email a census to Info@WesthouseAgency.com (include name, date of birth, & home zip code for each employee)

I will provide employee information via this survey form

Question Title

* 3. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 4. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 5. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 6. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 7. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 8. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 9. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 10. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 11. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 12. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 13. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 14. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 15. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 16. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 17. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 18. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 19. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

Question Title

* 20. Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code