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Group Health Insurance Online Quote

All fields marked with an asterisk (*) are required to complete the form. However, please complete as many fields as possible to ensure that we can prepare your quote as soon as possible.

Please note that Keystone Insurers Group cannot guarantee the security of any information you submit through these forms. If you feel uncomfortable submitting personal information over the Internet, but wish to learn more about our company, products or services, please give us a call at 814-781-7234.


Group Information

* Group Name:

* Group Address 1:

* Group Address 2:

* City:

* State:

* Zip Code:

* Contact Name:

* Contact Phone (Day):

*Email Address:

Fax:

* Current Deductible
(ex. - $500):

* Current Plan
(ex. - 90/10 to 70/30 to $5000):

* PPO you want quoted:

Current Insurance Carrier/HMO
(ex. - Blue Cross, Humana):

 

Group Health Census
For groups with more than 12 employees, attach your census here (Microsoft Word (.doc) or Adobe Acrobat (.pdf) --------->
   

Employee Name

Gender

Age or Date of Birth

Status
 

Details

Any comments or question?