E-mail Address:
*
Group Name/Contact Person
*
Nature of Business
Telephone Number
*
Fax Number
Total Number of Employees
*
Number of Full Time
*
Number of Part Time
*
Deductible Desired
$500
$750
$1,000
$1,500
$2,000
$2,500
$3,000
Higher
Benefits Desired
(check all that apply)
*
Physician Co-Pay
Maternity
Life Insurance
Drug Card
Short Term Disability
Dental
Please list any ongoing, serious medical conditions or pregnancies.
*
Required
mcf
Georgia Insurance Commissioners Office
Website Design by
Christin's Web Design
