Phoenix, Arizona Health Insurance Plans - Don Rice and Associates Don Rice and Associates - Healthcare Benefits
Don Rice Benefits, Your link to healthcare benefits in Scottsdale, Phoenix, Arizona
 
 

Group Coverage Quote Request
 
 
Company Name:
Address:
City:
State:
Zip code:
Contact Name:
Phone:
Fax:
Email address:
   
 
Do you currently have an agent or broker?     Yes    No
Is there a group plan in place now?     Yes    No
If Yes, complete the following:
Carrier: 
HMO PPO HSA Other
Premium:     Deductible Amount: 
   
 
Number of Employees:
Number of Part Time:
Number of Full Time:
Number of Employees to Cover:
Years in Business:
   
Reason for Change:
   
 
 
Please note: Group health benefit plans must meet certain eligiblity requirements. Information requested within this questionnaire is mandatory in order to start the quoting process. Feel free to contact Don Rice & Associates if you have any questions or concerns.
 
 
Don Rice & Associates, LLC • Your Link to Healthcare Benefits • Scottsdale, Arizona • 480-699-5745
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