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Small Business Information

1.Business Name(Required.)

Primary Contact:

Primary Phone Number:

Primary Email:

Business Address:

City

Zip Code

Do you have employees outside of Michigan that will need coverage?

When do you need coverage to start?

Who is your group plan through now?

Do you want to offer additional benefits such as life insurance, dental, vision or disability benefits to the employees?

Do you want to offer a retirement savings plan or 401K to your employees?

Do you want to offer a Health Savings Account, Flex Spending or Health Reimbursement Account to employees?

How much of the premium, if any, will the employer contribute toward the employee monthly health insurance premium?

Other concerns or considerations we should consider when researching health insurance rates and options?

2.Employee Census - email an employee census or manually enter them on this survey form.(Required.)

I will email a census to Info@WesthouseAgency.com (include name, date of birth, & home zip code for each employee)

I will provide employee information via this survey form

3.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

4.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

5.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

6.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

7.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

8.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

9.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

10.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

11.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

12.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

13.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

14.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

15.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

16.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

17.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

18.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

19.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

20.Employee

Name

Employee Date of Birth

Birthdates for each family member to be included in the quote

Home Zip Code

21.By submitting this form and providing my phone number I agree to receive text messages regarding appointment reminders and customer care messages from Westhouse Agency, LLC at the number provided. Consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. Privacy policy (HERE) and Term & Conditions (HERE)(Required.)

Agree