Client Login
CONTACT US
RHS Sales & Administration
800-548-7677, Ext. 121
707-525-4370
jnacol@rhs.org
Group Coverage Quote Request Form
COMPANY INFORMATION
Company name
*
Type of business
Business address
street
city
state
AA
AE
AL
AK
AP
AR
AZ
CA
CO
CT
DC
DE
FL
GU
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
zip
Contact name
*
Contact phone
*
Contact e-mail
*
Requested coverage
Medical
Dental
Vision
Requested effective date
----
January
February
March
April
May
June
July
August
September
October
November
December
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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
26
27
28
29
30
31
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2010
2011
2012
2013
2014
2015
Employees
Number of employees
Number enrolling in plan
Group coverage in past 180 days?
Yes
No
Current carrier
Current monthly premium
$
Employer premium contributions
For employees
%
For dependents
%
EMPLOYEE CENSUS
List the number of employees (EE) in each category
Age
EE only
EE/spouse
EE/children
EE/family
0-29
30-39
40-49
50-54
55-59
60-64
65+
*
required field
