Las Vegas Group Health Insurance

*Contact Name	*
Title
Company Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Contact Phone
FAX
*E-mail	*
*confirm E-mail	*
Contact By	E-MAIL PHONE FAX

Please provide the following product information:

Current Carrier
Proposed Effective Date
Current renewal Date
Company Structure	Select Sole Proprietor Partnership LLC Corp Other
More than 1 location?	Select Yes No
# of full time employees	(30+ hrs/ week)
How many weeks payroll
# of Cobra
% of cost to be paid by employer
Types of employees to be quoted	Select Management Hourly Salary Non-Union All
Employees Living out of state	Select Yes No
Industry SIC code
Need other products	Select Life Dental LTC None
# of employees

Known Medical Conditions?