HBAV

Contact Information
Name:
Phone:
Email:
Tell Us About Your Business
Company Name:
Address:
City:
State:
Zip:
Please describe the type of business you operate:
When would you plan on implementing your new health-care plan?	During the next month Within three months Before the end of the year
How many employees would be eligible for the new health-care plan?
What percentage of eligible employees would you expect to participate?
Policy Information
What co-payment amount would you like your employees to spend when visiting a doctor's office?	$10 $15 $20 More than $20 None
Would you like your employees to have a prescription co-payment card?	Yes No
What type of plan would best fit the needs of your employees?
What amount of hospital deductible is best for your policy?
What amount of coinsurance is best for your policy?
Do you want to offer group life insurance?	Yes No
Do you want to offer group dental?	Yes No
Comments
Is there any additonal information you would like us to consider as we process your request (preferred carriers, current situation, etc)?
Your information will remain confidential and a representative will contact you to discuss ways that HBAV Benefits Group can help your company with your health insurance programs.