Affiliated Insurance Agencies, Inc., St. Louis, Missouri | www.aiastl.com

Please take the time to fill out the following information so we can provide you with a free, no obligation insurance quote. Please provide as much information, as possible, for the most accurate quote. This information is confidential and will be used for quote purposes ONLY.

You will receive a quote by e-mail, fax or phone within 24 hours of submission of online questionnaire. You are always welcome to call an agent.

Business Heatlh for Individual
Business Health for Group of 1-12
Business Health for Group up to 24

Business Health Insurance for an Individual

*REQUIRED

Company Information

Company Name:
Company Address:
Second Address
City, State, Zip:
Number of Years in Business:
Contact Name:
Telephone: (add area code)
Fax: (add area code)
E-mail address :
How would you prefer to be contacted?
Description of Business:
Percent Company plans to contrubute:
Are you currently insured?

Employee Information
Name:
Gender:
Age:
Zip Code:
Dependent Coverage?

Health Plans and Options
Select Plan and Options you would like to receive:
Plans:

Options:



PPO (Preferred Provider Organization) - This flexible plan affords you the ability to choose any doctor or hospital form the PPO's directory or to use a doctor outside the plan at a higher expense.
POS (Point of Service) - This plan allows you to choose the level of benefits received. By coordination with a Primary Care Physician you'll receive a higher level of benefits. This plan also allows your to choose any doctor or hospital and receive a lower level of benefits.
Major Medical - This plan is favored by those who prefer to choose any doctor or hospital. This is the most unrestricted plan. Consumers are responsible to pay in full in advance for medical services they receive and file their own claims paperwork to seek reimbursement.
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