GIA, Ohio Insurance Agency

Group Health Quotes

For groups with more than 5 employees: Download and open the following file in Excel or Another Spreadsheet Program: Group Census Format Then complete the employee information fields and Email to this Address: GIA@neo.rr.com

For groups with less than 6 Employees complete the info below.

* = Required Fields

*Group Needing Quote Name:

*Group - Address:

* Group - City:

* Group - State:

* Group - Zip:

* Group - Phone Number:

* Group - Email Address:

Select Group Products to Quote:

Agent Name:

Agent Email:

Agent Phone:

Agent Fax:

Current Deductible:

Current Plan:

PPO You Want Quoted:

Current Insurance Carrier or HMO:

Group Health Census
Employee Names	Sex	Age or DOB	Status






Additional Comments: