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Life and Health Group Insurance Request a Quote

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Request a quote for your Group Insurance

Lewis Insurance Associates now offers you the ability to request a free, confidential quote online using the form below.

( * indicates required information)

*Business/Organization Name:
*Contact Person:
* Business/Organization Mailing Address:
*City:
*State:
*Zip Code:
*Business Location: (if different from mailing address)
*E-mail address:
*Phone Number:
Website Address:
Tell us about your employees: (If you have more employees than listed please complete another quote or contact us with that information.)
Employee 1:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:

Employee 2:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:

Employee 3:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:

Employee 4:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:

Employee 5:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:

Employee 6:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:

Employee 7:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:

Employee 8:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:

Employee 9:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:

Employee 10:	Name:		Age:
Occupation:			Sex:	Male Female
Salary:
Coverage:		Single Employee and child	Employee and Spouse Family: Number in family:


Tell us about your current plan:
Health Care Provider:
Health Rates:		Single		Employee and child
		Employee and Spouse		Family
Do you have a dental plan?		Yes No
Dental Rates:		Single		Employee and child
		Employee and Spouse		Family
Do you have a deductible?		Yes No	If yes, amount:
Do you have a prescription plan?		Yes No	If yes, amount:
Life rates:		/$1000	AD&D rates: /$1000

REMEMBER! Completion of this form constitutes a request for a quotation. It is not intended to replace or act as an actual insurance contract or binder.