ARG & Associates

ARG & Associates will provide you with a free, no-obligation Group Health Insurance quote. The information below is kept confidential. Please answer as many questions as possible, so we can provide you with the most accurate quote.

Group Health Insurance

Company Information

Company Name: Date:

Contact:

Address:

City:

State:

Zip:

Phone: Best time to call: am pm

Fax:

E-mail:

Insurance Information

Currently Insured with:

Policy Number: Policy Expiration Date:

Premium Amount: $ Insured Amount: $

Term of Insurance: 6 months 1 year other:

What other types of insurance coverage do you have relating to your business? (Please list below):

Insurance Type Premium paid per Year Expiration Date

Business Liability $

Business Auto $

Business Umbrella $

Workers' Compensation $

Professional Liability $

Liability for Corporate Executives $

Group Health $

Group Life $

Group Retirement/401k/etc. $

Surety Bonds $

Other: $

Company Financial Information

What was your past years Annual Income: $ Projected Current Year: $

Cash: $ Securities: $ Other income: $

Amount of inventory: $

Amount of Supplies: $

Amount of Equipment: $

Amount of other Assets: $

What was your past years Annual Payroll: $ Projected Current Year: $

How many years has the company been in business?

How many Full Time employees do you employ?

How many Part Time employees do you employ?

Do you have any contract labor? Yes No, if yes, how many contractors do you have?

Please describe your business below:

Employee List

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If you require additional space please reset form after you send original information reuse form as many time as needed to complete your information. Please only fill in company name at the top and in the contact space fill in page number. (Example: Contact: Page 3 of 4)

Additional Details

Please list below any additional details in the space provided below:

When you click "Submit Quote" button, your application will be emailed to one of our representatives, who will contact you shortly.