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"Group Health Insurance Questionnaire"

Group Health Insurance Questionnaire
Please take five minutes of your time to find how much you can save. It is understood that this is not an application for insurance. There is no obligation and no sales person will call or visit me.
J. Byrne Agency, Inc.
5200 New Jersey Ave., Wildwood, NJ 08260
Phone 609-522-3406 / Fax 609-522-2844
Website: www.jbyrneagency.com

GENERAL INFORMATION
Client Name:
Contact Name:
Position:
Street Address:
Apartment/Unit #:
   
City:
State:
Zip:
E-mail:
    
Home Phone:
Business Phone:
    
Cell Phone:
Fax:
    

BUSINESS DESCRIPTION
Business Type:
Industry:
Federal Tax ID:

TYPE OF HEALTH CARE INSURANCE YOU ARE INTERESTED IN
Number or Employees:
Number Insured:
Employer contribution (%)
Any affiliated companies?
Current Policy Renewal Date:
Please check all that apply:
 HMO  PPO  POS  Prescription Plan  Dental  Life  Long Term Disability 
In network deductible and coinsurance ($)
Out of network deductible and coinsurance ($)
Referral required:
    
Office visit Co-pay ($)
Hospital Co-pay ($)

HEALTH CENSUS
Employee Name Date of Birth Date of Hire Gender Full or Part Time Coverage Job Position Home Zip Code


WHO COMPLETED THIS FORM?
Full Name:
Today's Date:

FAIR CREDIT STATEMENT

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I Have Read the "Fair Credit Statement - and I AGREE to the terms set forth.

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Wildwood, NJ
5200 New Jersey Avenue
PO Box 1409
Wildwood, NJ 08260
Phone (609) 522-3406
Fax (609) 522-2844

Marmora, NJ
200 Route 9 South, Unit 1
Marmora, NJ 08223
Phone (609) 390-5566
Fax (609) 390-5577
Cape May Court House, NJ
1032 Route 9 South
Cape May Court House, NJ 08210
Phone (609) 465-7710
Fax (609) 465-9346
Cape May , NJ
917 Madison Avenue
Cape May, NJ 08204
Phone (609) 884-3333
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