2. How many full time employees do you have?

4. Do you offer other benefits?

4. Briefly describe your current Health plan design.

Current Rates?

Deductible amount/office co-pay

Single

Single + 1

Single + Children

Family

# of Employees

# of Employees on the Plan

Phone

City, State  Zip

Company Address

Fax

Email

6. Contact Information

1. Who is your current health insurance provider? 

First Name

Last Name

Your Company name

How would you like me to contact you?

5. What other benefits do you offer?

Please take 2 minutes to fill out this information to get your free quotes.

Jason Marty

Insurance & Investment  Professionals, Inc.

1111 Deming Way

Madison, WI 53717

608.334.9367

jmarty@iipros.com

YesNO

Phone AMPhone PME-MAIL