Free Quote Request Form

Fill out the form below to receive a free no-obligation quote for group health, dental or vision insurance from A-rated carriers like United Healthcare, Blue Cross Blue Shield, Aetna and Cigna. Planning Services is a broker for group businesses only; if you are looking for individual coverage do not fill out this form. All items with asterics are required to obtain a quote.

If you would prefer we can come out for a free consultation or we can gather the information by phone.

Please allow 3-5 days for the quotes to process with the carriers. We will email you the qoutes as soon as we receive them.

Quote Request Form

Company Name *

Contact Name *

Job Title

Phone *

Company Address *

City *

State *

Zip *

Email (we will keep your email completely private) *

Industry/SIC Code *

Do you currently offer health insurance?

Tell us about your current plan - check all that apply.

PPO
HMO
Fully-Insured
Self-Insured

Who is your current carrier?

List your current rates for EO, ES, EC, & EF

List your current deductible amounts for individual and family.

What group benefits are you interested in? Check all that apply.

Health
Dental
Vision
Life

If interested in a dental quote, do you want it quoted with orthodontia?

If interested in medical, do you want to include maternity?

If you have 10 or less employees, list the birthdate,gender,home zip code and who they are covering (EO, ES, EC, EF- if you know; if not we will just quote for EO) for each employee in the box below. If you have more than 10 employees or if you would like, email a census to kelly@planningservices.com OR when you complete this form, you will have the option to download a census form if you do not have one. Instructions for submitting this form are on the next page. *

Why are you looking to add/change your current insurance?

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