1. What is the number of full-time employees participating in your group health insurance policy?
 
  1-20   21-50   51-100   More than 100
 
2. What month does your current group health insurance renew?
 
  Health:
  Life:
  Disability:
  Dental:
  Vision:
 
3. Who is your company’s group health insurance carrier/broker?
 
 
 
4. Would you like:
 
  • A NO-OBLIGATION premium/benefit comparison from all available insurance carriers in your area for: (Check plans you would like provided)
  Health
  Life
  Disability
  Dental
  Vision
   
  • Information on alternative insurance funding options such as Health Savings Accounts or Health Reimbursement Accounts?
 
Yes   No
   
  • To speak to a Patton Group Insurance Professional about your company’s employee benefits program?
 
Yes   No
 
If you have other questions or comments, please type them here.
 
   
   
 
Your Name:
 
Your Company's Name:
 
Daytime Phone Number:
 
Email Address:

 
 
  Enter the code below as it is shown.
 
 
   
   

Thank you!

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