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CHC CENSUS
*Please put "N/A in box if not applicable*
Agent Name
Phone Number
Email
Client Information
Address
City
State
Zip Code
Type Of Business
# Of Employees
ATNE
# Of Locations
Client's Budget
Plan Design
Have they had insurance previosly
Type
With Who
Have they ever worked with a broker
Are they currently working with a broker? Who?
Do they currently have insurance? If Yes See Below
Why are they looking for coverage
Current Carrier
HSA Y/N
HRA Y/N
Number of plans offered
Current rates and renewel rate
Copays
OPP
Deductible
Community or age brand premium
% paid by employee and % paid by employer
# Of Employees Enrolled
If No
Why are they looking for health insurance now for their group
Perferred Copays
Perferred OPP
Perferred Deductible
Have they considered a monthly budget for their premiums
Would they like to present voluntary employee paid dental, vision, or other to offset out of pocket costs? (Y/N - Which?)
Do they offer life or disability
Would they like quotes
Preferred Carriers to quote
Carriers to avoid
Submit
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