If you think you may qualify for group coverage, please submit this form for quote request - Fields will appear as needed Please enable JavaScript in your browser to complete this form.Name *Business NameEmail *PhoneType of Business (Industry)# of Employees *1234If 5+, request census formBusiness Org *Sole ProprietorLLCS CorpC CorpPartnershipOtherBusiness Zip *County Business is in?KingSnohomishEmployee Data: (If spouse employed list separate. Dependent DOBs required. Request census form if 5+)DOB or Age on Jan 1st. DOB for accurate quote. Children under 26 only.#1 Employee NameOwnerYesNoIncome TypeProfits (Distributions)W-21099W-2 & ProfitsOtherDid you receive a W-2 for Prior Year Income?YesNoNot SureNot from this companyNot last calendar year, but I will this calendar yearAge or DOB *Coverage Type *Employee OnlyEmployee & SpouseEmployee & ChildrenEmp, Spouse & ChildrenWaivingWaiver ReasonOn Spouse GroupOn Parent Group (age <26)On MedicareTriCare (VA)Individual or Exchange PlanNoneWho is current coverage with? Group or Individual?Spouse Age or DOBChild 1 Age or DOBChild 2 Age or DOBChild 3 Age or DOBChild 4 Age or DOBPlease elaborate on when your W-2 income started (important qualifier)#2 Employee NameOwnerYesNoIncome TypeProfits (Distributions)W-21099W-2 & ProfitsOtherReceived W-2 for Last Calendar Year?YesNoNot SureNot from this companyNot last calendar year, but yes for this calendar yearAge or DOB *Coverage Type *Employee OnlyEmployee & SpouseEmployee & ChildrenEmp, Spouse & ChildrenWaivingWaiver ReasonOn Spouse GroupOn Parent Group (age <26)On MedicareTriCare (VA)Individual or Exchange PlanNoneWho is current coverage with? Group or Individual?Spouse Age or DOBChild 1 Age or DOBChild 2 Age or DOBChild 3 Age or DOBChild 4 Age or DOB#3 Employee NameOwnerYesNoIncome TypeProfits (Distributions)W-21099W-2 & ProfitsOtherReceived W-2 for Last Calendar Year?YesNoNot SureNot from this companyNot last calendar year, but yes for this calendar yearAge or DOB *Coverage Type *Employee OnlyEmployee & SpouseEmployee & ChildrenEmp, Spouse & ChildrenWaivingWaiver ReasonOn Spouse GroupOn Parent Group (age <26)On MedicareTriCare (VA)Individual or Exchange PlanNoneWho is current coverage with? Group or Individual?Spouse Age or DOB *Child 1 Age or DOB *Child 2 Age or DOBChild 3 Age or DOBChild 4 Age or DOB#4 Employee NameOwnerYesNoIncome TypeProfits (Distributions)W-21099W-2 & ProfitsOtherReceived W-2 for Last Calendar Year?YesNoNot SureNot from this companyNot last calendar year, but yes for this calendar yearAge or DOB *Coverage Type *Employee OnlyEmployee & SpouseEmployee & ChildrenEmp, Spouse & ChildrenWaivingWaiver ReasonOn Spouse GroupOn Parent Group (age <26)On MedicareTriCare (VA)Individual or Exchange PlanNoneWho is current coverage with? Group or Individual?Spouse Age or DOB *Child 1 Age or DOB *Child 2 Age or DOBChild 3 Age or DOBChild 4 Age or DOBOther Questions:How did you hear about us?Green Financial Client?YesNoIn PastAre there significant health or prescription issues? (this simply helps in our recommendation)Besides those listed above, have you paid anyone else on a 1099 or W-2 basis, even if only a few hours per week?YesNoUnsureIf yes, please explain. This information may help you qualify for a group plan even if this person is not eligible for coverage.Comment or MessageHealth Savings Account (check all that apply)I am familiar with HSAsI have an HSAI would consider an HSAI do not want an HSAI would like to learn more about HSAsOther Comments (check all that apply)Need great prescription coverageI want lowest deductible available (rich plan)I want least expensive plan possibleI don't want provider restrictionsI don't care if I have to change doctorsCheck if access to these particular hospitals/systems are important to have access to (certain carriers may exclude them)CHI FranciscanSwedishProvidenceI don't care if I have to change doctorsSubmit MUST PRESS SUBMIT
