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Large Group Enrollment Form

Large Group Enrollment Form

If your group has more than 50 people, please fill out the form below and one of our representatives will reach-out to you shortly!

Name of Group*
How many total employees?*
Please enter a value greater than or equal to 50.
Eligible Employees?*
Employees Enrolling?*
State group is located in?*
State / Province / Region
Requested Effective Date*
Multi-Location Group? (must be in different counties)*
- Yes
- No
Common Ownership?*
- Yes
- No
Agent quoting contact information:
Name
First Last
Company*
Phone
Email
Are you the current/in force agent?*
- Yes
- No
If No, explain (explanation not required)
Are you currently appointed with all carriers quoting?*
- Yes
- No
Please be sure to obtain the following:
- Census from the group in excel format ONLY, including Name, gender, DOB, resident zip code, and coverage elections (including waivers) *Please note UHC requires dependent information if group size is 51-99
- Current and Renewal Rates for each line quoting
- Current Benefit summary for each line quoting
Comments
Comments
This field is for validation purposes and should be left unchanged.

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AgentLink Kentucky Office
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Louisville, KY 40223
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