Costello Insurance Agency, Inc.

2 South Kimball Street, P. O. Box 5248
Bradford, MA 01835

Phone: 978-374-6352     Fax: 978-521-5127

Please be advised that insurance coverage cannot be bound, modified, or terminated by e-mail messages or information provided to us via the web. Any information you submit will be used solely for the purpose of quoting insurance options, and does not in any way constitute an agreement of coverage.

Group Health Insurance Quote

Company Name:
Address 1: City:
Address 2: State: Zip:
Contact Person: Contact Email:
Office Phone: (with area code)
Ext:
Fax: (with area code)
Best time to contact:

General Information

  1. Type of Business:

  2. SEC Code:

  3. Number of Employees to be quoted:

  4. Employee Census

    E = Employee, ES = Employee + Spouse, EC = Employee + Child, F = Family, W = Employee Waving Coverage

    Feel free to FAX or email your current census to our office: 978-521-5127

    Sex Date of Birth Single or Family If family,
    how many kids?
    COBRA Enrollees
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  5. Renewal Date of existing policy (DD/MM/YY)

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  6. Current Insurer, if any

  7. Please Enter Company Contribution % or Flat Amount

  8. Type of Plan

  9. Hospital Co-payment Amount

  10. Office Visit Co-payment Amount

  11. Rx Co-payment

  12. Description of business

  13. Has the company been in business for over one year?

    Yes No

  14. Do you currently maintain medical coverage for your employees?

    Yes No

    If insured, list the company insured with:

    Current Monthly Group Premium:

  15. Select the type of quote and options you would like:

    Medical Idemnity

    HMO/Managed Care

    PPO

    Health Savings Account

    Life Insurance

    Disability Insurance

    Dental Care

    Vision Care

    Don't Know / Want to discuss

  16. Section 125 POP?

    Yes No Don't Know

  17. Do you use a Broker?

    Yes No

    If yes, name of current broker:

  18. Please list primary state of residence for employees?

    List any other states where employees reside:

  19. Have you had any large claims over $10,000 in the past 12 months?

    Yes No

  20. Questions and/or Comments

Important Note: Quotes will be based on the information provided. It is only a rate calculation and is not binding in any way. A full application must be completed and signed by the named insured.