Employer Group Health Application

Group Insurance

Personal Insurance

Thank you for your business!

Please complete this short form to begin the application process. The information you provide on this form will be used to complete your application. Providing complete information will save you time and speed up your approval.

Please Do not cancel or alter your existing health insurance until we notify you of approval (usually in about 14 business days).
If you have any questions or need our assistance, call us at: 1-914-633-1717 and we will be glad to help you.

Yes! I would like to apply for a Group Health Plan

Current Health Plan*
Name of New Plan*
Your Company Name*
Address
City State ZIP Code
Contact Name*
First Last
Contact Title
Email*
Phone*
Start Date of Business
MM slash DD slash YYYY
Business Type
- S Corp
- C Corp
- LLC
- Partnership
- Sole Proprietor
# of Employees
# of Employees Enrolling