Rosenthal Bros, Inc.

Creative Solutions
for Business.

Small Group Insurance

In order to provide you with a quote on your Small Group (under 25 employees), please complete the following information. If you are interested in a quote for your company and there are over 25 lives, please contact us direct.

Company Name
Address
City
State
Zip Code
County
Contact Name
Contact Email Address
Nature of Business
Years in business		SIC Code
# of employees		Requested Effective Date

What are the TWO most important factors when choosing health insurance?

Price
Type of plan & benefits
Doctor/Hospital provider network
Specific Insurance Company
Your personal relationship with an agent
Other:

CURRENT RATES
	EMPLOYEE	DEPENDENT
Current
Renewal
Employer Contribution	%	%

About your current health plan...

Current Carrier
Years with them
If less than 1, prior carrier
Type of Plan
Deductible
Co-Insurance	TO
Drug Card
Office Visit Copayment
Supplemental Accident
Dental
Vision
Short Term Disability
Long Term Disability

To the best of Employer knowledge on available information, is any employee or dependent:

Currently Pregnant
If Yes, expected date of birth
Currently disabled or hospital confined
If Yes, please explain
Received treatment for cancer, heart, stroke, diabetes, kidney disorder, immune system disorder, psychological, alcohol or drug disorder
If Yes, please explain
Have there been any claims in excess of $5,000 over the past year
If Yes, please explain
Is anyone on COBRA
If Yes, please give names and qualifying dates

Finally, we need your census information:

EE #	Employee Name	EE DOB	EE Status*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Submission of this form is for quoting purposes only. You will be sent a confirmation that the form has been received and we will begin processing your request. The quoting process can take up to 3 weeks and we will be in contact with you to advise of the ongoing status.