Request a Quote

 

 

To order your FREE quote, complete the form below.  If you have any questions on how to complete the form, please call us in the office or send us an email. 

Please take a few minutes to tell us about your company  The information you provide is confidential and will help us customize your health insurance coverage.

You may opt to click the "printer freindly" icon to download a PDF version that you can fill out offline and fax to us at 704-543-9612.  Or you can call us at 704-543-9314 for a free consultation or if you have any questions

 

Group Name:
Address:
City:   State:   Zip:
Contact Person:    Title:
Phone:
Current Carrier:     Renewal Date:
Email

SELECT THE GROUP COVERAGE(S) YOU WOULD LIKE QUOTED:

HEALTH   DENTAL    LIFE    DISABILITY (We will request salaries/occupation)

WHO WILL BE INSURED?

 

Name

Gender

DOB

Check if
Covering Spouse
Number of
Dependents
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


(We use this code to discourage spamming)

  

 

7427 Matthews-Mint Hill Rd.  Suite 105-222 Mint Hill, NC 28227
Main(704) 543-9314  Fax  (704) 543-9612
carroll@groupinsurancesolutions.com