HAP | Health Insurance | Get a Group Quote

First Name:

Last Name:

Company Name:

City:

Zip Code of Business:

Number of full time employees:

Phone:

E-mail:

Select preferred method of contact:

Individual E-mail Phone

Do you currently work with an agent?

Yes No

If yes, what is your agent's name or agency?

Who is your current health insurance provider?:

Other provider:

When is your renewal date?:

What is most important to you when selecting a plan? (Check all that apply) :

Funding options (fully insured, self/shared funded)

Health Savings Accounts

Health Reimbursement Accounts

Flexible Savings Accounts

Platform purchase options (private exchange, SHOP)

Which is more important to your business?:

Size of Physician Network Monthly Premium

Why are you shopping for insurance? (Check all that apply):

Exploring cost savings options

Seeking better customer service

Seeking better medical coverage

Provider network access

Need an ACA-compliant plan

Other (please specify)

Other reason: