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Request a Quote

Click here to download a pdf version of this form to send via email.

Your name

Your email address

Subject

Message

Name of Group

Primary Location

Number of Employees

Additional Locations

SIC/NAICS Code

Current Insurance Carrier

Unique Employee Characteristics

Effective Date w/Current Carrier

Nature of Business

Requested Effective Date

Benefits Requested

Medical

Dental

Vision

Rx

Current Funding

Fully Insured

Fully Self-Funded

Partially Self-Funded

Other

Requested Funding

Fully Self-Funded

Partially Self-Funded

Other

Specific Contract Type

24/12

12/12

12/15

Agregate Contract Type

24/12

12/12

12/15

To be Included in Aggregate (In Addition to Medical)

Prescription Drug

Dental

Vision

Single

Family

Current Rates

Renewal Rates

Specific Deductible to Quote

Unique Benefit Characteristics

Networks (Primary and Wrap)

Prescription Drug

Utilization Review

Requested Commission

Date Due Back to Broker

Broker Contact Information

Completed By

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Copyright Kentucky Health Administrators
1721 Fortune Court, Suite 150
Lexington, Ky 40509
866-664-3261

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