Scarborough & Associates - Group Health Quote

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Group Health Quote

Group Health Insurance Quote

Group Name:

Telephone:

Group Contact:

Fax:

Group Address:

City, State & Zip:

E-Mail Address:

Current Health Carrier:

Effective Date:

# of employess:

Cobra Employees

How long in business:

Worker's Compensation?:

Employees in waiting period:

Group Census
(If More Than 10 Employees, please call us to receive a large group census form.)


Employee #	Birth Date (mm/dd/yy)	Gender	Zip Code	Select Coverage
# 1		Male
		Female
# 2		Male
		Female
# 3		Male
		Female
# 4		Male
		Female
# 5		Male
		Female
# 6		Male
		Female
# 7		Male
		Female
# 8		Male
		Female
# 9		Male
		Female
# 10		Male
		Female

Additional Comments

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We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
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Scarborough & Associates Insurance
260 Gateway Drive, Suites 11-12A
Bel Air, MD 21014
Toll Free: (800) 696-3743
Maryland: (410) 838-7206
Fax: (410) 838-8185

Proudly serving Bel Air, MD and Harford County, Maryland.