Group Health Profile

Company Information
Today's Date Required Today's Date is required.	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10
Requested Effective Date Required Requested Effective Date is required.	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10
Company Name Required Group Name is required.
First Name Required Input Required
Last Name Required Input Required
Type of Industry Required Type of Industry is required.
Total W-2 Employees Required Please enter the total number of W-2 employees
Total Number of 1099 Employees Required Undefined
Street Required Input Required
City Required Input Required
State Required Input Required	select LA
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
Primary Phone Number Required Input Required Please enter a valid phone number
Fax Number Optional
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
Current Benefit Plan
Current Group Health Company Optional
Current Premium Optional
Health Plan Optional	select HMO PPO POS HSA Other
Deductible Amount Optional	select Over 2500 750 1000 1500 2000 2500
Co-insurance Optional
Prescription Deductible Optional	select 100 200 250
Prescription Co-pay Optional
New Employee Waiting Peroid Optional	select 30 Days 60 Days 90 Days 180 Days
Serious or Chronic illness or injury Optional	Yes No
Serious illness or injury description Optional
Other Employee Benefits Optional	Life Dental Disability Cafeteria Plan Vision Hold down the Ctrl Key to make multiple selections.
Ancillary Company Optional
Enter Validation Code Required

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