Archer A. Associates, Inc. - Insurance Agents and Brokers
Group Health Quote
General Information
Contact Name*
Contact E-Mail*
Name of Business*
Address *
Street Address
Address Line 2
City State / Province / Region
Postal / Zip Code

Country

Business Phone *
### - ### - ####  
FAX
### - ### - ####  
Group Health Coverage
Number of Employees
Number of Employees Eligible
Number of Employees on Plan
Number Single
Number Employee + Spouse
Number Employee + Children
Number Employee + Family
Current Carrier
Current Plan
HMO
POS
PPO
Indemnity
Plan to Quote
HMO
POS
PPO
Indemnity
Desired Deductible
Desired Co-Pay
Desired Co-Insurance
Comments
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