Seven Corners Major Medical Group Quote Request

Step 1 of 2: Administrative Information

Group Name:
Street Address:


City:		State:
Zip:	-
Country
Contact:		Title
Phone:*		Fax
Email:*
Effective Date
Nature of Business:

Seven Corners Agent Number:* If applicable

File Upload 1: If applicable	Clear
File Upload 2: If applicable	Clear
File Upload 3: If applicable	Clear
Note: For a binding quote and proposal please attach a complete and accurate census including Dates of Birth, Gender, Locations, and Nationalities of all Employees and eligible Dependents.
* In order to respond to your request for a quote a phone number, email address, or Seven Corners Agent Number is required.

Step: 2 of 2: Group Eligibility

Eligible Employees:

Total Number of Employees

Total Number of Eligible Employees

Total Number Applying for Coverage

Coverage is...

Mandatory

Voluntary

Has the number of employees stated above increased or decreased by more than 10% in the past 24 months and/or will it increase or decrease by more than 10% for the requested period of coverage?

Yes
No

If Yes, please explain...

Please define class or classes of employees to which insurance is to apply if insurance will not apply to all employees (i.e. Managers, Staff, Executives, etc.).

Employee Profile Breakdown

For a non-binding proposal please provide a summary of Employee Units below.

Age	Male Employees			Female Employees
Age	Employee Only	Employee +1	Family	Employee Only	Employee +1	Family
19-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+