Get A Quote

This page provides several forms helpful in gathering the required information to quote and eventually apply for health benefits. Below is a list of our forms. Please select the one that fits your needs, download and print the form. After filling out the form, you can mail or fax the form to our office. These forms require Adobe® Acrobat® Reader™ to be viewed and printed. Many people already have Acrobat Reader loaded, if not, we have a link for their FREE download. Click Here for tips on installing Adobe Acrobat Reader.

Online Forms - Some companies may already have their employee health census data available in a spreadsheet or other data format. We can usually aid you in transferring that electronic file to us, to save you work! Just complete our online census form or drop us an e-mail. Of course you could always just give us a call, and say HELP! 1-800-798-6772.

You might have questions or concerns regarding some of the items on the form. To help you better understand why certain information is requested on the forms Click Here

	Please feel free to run your own CoventryOne Individual quotes. Click on the CoventryOne Get a Quote Now image. If you have any questions feel free to contact us at 1-800-798-6772. (State of Iowa, Nebraska and South Dakota Quotes Only)) Quotes for other states contact AMGI Toll Free 800.798.6772 or by e-mail at mail@amgi-dsm.com
	If you would like to obtain a Wellmark individual quote. Please contact us toll free at 1-800-798-6772 or complete this Individual Census and fax it to 515-270-0398 attention to Christen Norris.
	Please feel free to run your own Assurant Individual quotes. Click on the Get a Quote Now! image. If you have any questions feel free to contact us at 1-800-798-6772.
	Please feel free to run your own Spirit Dental Individual quotes in all states except NEW YORK. Click on the Spirit Dental image. If you have any questions feel free to contact us at 1-800-798-6772. Printable Spirit Dental Benefit, Rates and App Forms:     Spirit Dental - Most of US     Spirit Dental - CT, ME, NH, NJ, RI -            Need Info? Call us Toll Free 1-800-798-6772     Spirit Dental - Maryland Only     Spirit Dental - Florida
	(State of New York Residents) Please feel free to run your own Delta Dental Individual quotes. Click on the Delta Dental Logo. If you have any questions feel free to contact us at 1-800-798-6772.
	Click on the Aetna Logo to get a quote now. If you have any questions feel free to contact us at 1-800-798-6772.

Download and print the following PDF form that fits your needs. Complete the form and mail or fax to our office. Information is on the form.
FORM	DESCRIPTION
Individual Census	This form is for an individual or family requesting a quote for health benefits.
Group Census	This form is for companies with up to 12 employees that wish to look into rates for a group plan. If you have more than 12 employees, download this form and then download the Group Census Addendum in addition to this form, to fill out for the additional employees.
Group Census (Addendum)	This form is basically page 2 of the Group Census. It just provides additional blanks for groups larger than 12.
	Adobe® Acrobat® Reader™ is a FREE software product that allows you to view and print forms and documents that are created using PDF (Portable Document Format) files. These files can be passed easily over the Internet, and printed on a variety of printers as they were meant to be seen on all major platforms like Windows, Apple Macintosh, Linux, UNIX, and more. Your system may already have Acrobat Reader installed, but if not, you can click on the icon at the left to download and install Acrobat Reader. For Tips on installing Adobe Acrobat Reader Click Here.