Employee Health Insurance Quote Connecticut

**Information received from this CT Group Health Insurance plan quote request form
sent to the William Malloy Insurance Agency will be for our use only and will not be
sold, given to or distributed to any other parties. A quote will be based on the group
health insurance policy plan information provided and does not guarantee
acceptance of the risk by us. The precise coverage afforded is subject to meeting
underwriting guidelines, and the terms, conditions and exclusions of the policy as
issued. By submitting this request you acknowledge that this is neither an offer to
insure nor a guarantee of insurance. Completion of this form does not entitle your
Connecticut business to Group Health Insurance. We are licensed in Connecticut
and will not provide quotes for other states.

We are your local Fairfield County insurance agency, offering affordable group
health insurance plans and services in the following Connecticut cities and
counties: Stamford, Norwalk, Greenwich, Darien, Riverside, Belltown,
Springdale, Round Hill, Old Greenwich, East Norwalk, New Canaan, Glenville,
Byram, Cos Cob, Mianus, North Stamford, Glenbrook, Wilton, Weston, Long
Ridge, Noroton, West Norwalk, Westport, High Ridge, Southport, North Wilton,
Winnipauk, Cannondale, Turn of River, South Wilton, Lyons Plains, Georgetown,
Ridgefield, Branchville, Redding, Topstone, Ridgebury, Redding Ridge,
Branchville, Dodgingtown, West Redding, Titicus, Hattertown, Bethel, Danbury,
New Fairfield, Newtown, Hawleyville, Botsford, Monroe, Bridgeport, Stepney,
Shelton, Huntington, Upper Stepney, Long Hill, Trumbull, Stratford, Easton,
Fairfield, Greenfield Hill, Stratfield, Nichols, Oronoque, Rivercliff, Devon, Lordship,
and East Bridgeport, New Haven, Hartford, Torrington, Waterbury, Meriden, New
Britain, New London, Norwich, Manchester, East Hartford, Suffield, Granby,
West Haven, West Hartford, Branford, East Haven, Hamden, Woodbridge,
Orange, North Haven, Groton, Rocky Hill, Newington, Wethersfield, Glastonbury,
Bloomfield, Blue Hills, South Windsor, Naugatuck, New Hartford, Chesire, East
Lyme, Old Mystic, Wallingford, Southington, Middletown, Bristol, Laurel Beach,
Litchfield, Pleasure Beach, Mystic, North Westchester, Double Beach,
Willimantic, Storrs, Canaan, East Windsor, Vernon, South Canaan, Putnam,
Guilford, Windham, South Britain, Willington, Windsor, East Hampton, Brooklyn,
Westchester, and everywhere else in New Haven County, Litchfield County,
Middlesex County, New London County, Hartford County, Tolland County and
Windham County, CT.

In addition to Group
Health Insurance for your
Connecticut business, we
also offer affordable
Employee Life Insurance
plan premiums or choose
another CT business
insurance coverage from
the list below.

Business Name:
Premises Address:
City:     State:     Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required)
Description of Operations or SIC code:

Current Insurance Company:
Policy Expiration Date:          (mm/dd/yyyy)

Do you currently offer health insurance benefits to employees?
Group Health Insurance Coverage For:
How many employees to be insured:

HMO Group Health Insurance   HMO Co-Pay Amount Desired:
PPO Group Health Insurance     PPO Deductible Amount Desired:
POS Group Health Insurance     POS Co-Pay Amount Desired:
Fee-for-Service Insurance          Fee-for-Service Deductible:

Choose Benefit Options:
Group Dental Insurance Coverage:
Group Vision Insurance Coverage:
Group Life Insurance Coverage:

Has any employee to be insured experienced serious health
problems during the last 18 months?
If "Yes", please explain below.

Additional Information or Comments

Click on the "Submit Quote Information" button below to send your
Connecticut Employee Health insurance quote request.**

Connecticut Group Health Insurance Coverage Desired:

Connecticut Business Information:

Employee Information: