Contact Us for a Quote
 
Your Name: *
 
Phone Number: *
 
Email: *
 
City: *
 
State: *
 
 
ZIP Code: *
 
Best time to contact: *
 
Enter your message *
 
 
 
Mailing Response (Fields marked * are required fields)

         
  Company Name: *    
         
  Address: *    
         
  City: * State: * Zip: *
         
 
Phone: * Fax:*  
         
  Nature of Business: *    
         
  Email Address: *    
         
  Contact: *    
         
  Current Carrier: *    
         
  Current Plan Name: *    
         
  Deductible: *    
         
  Doctor Copay: *    
         
  RX Copay: *    
         
  Current Monthly Premium:*    
         






Employee Census
                   
  Employee Name / Smoker or Non Male or Female Date of
Birth
(mm-dd-
yyyy)
Type of Medical Coverage (see codes below) Spouse
DOB
(mm-dd-
yyyy)
Dates of Birth of Children
(mm-dd-
yyyy)
Residential Zip Code Household Yearly Salary  
                   
   
                   
   
                   
   
                   
 
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
                 
                   
Coverage Codes for Medical:
EE = Employee Only
EC = Employee + Child(ren)
ES = Employee + Spouse
EF= Employee + Spouse and Child(ren)
W - Waived, not taking coverage





© Copyright 2020 FREED AGENCY INC. All Right Reserved.