Kentucky Group Health Insurance Quote from Eugene Wilson & Co. LLC Insurance Agency of Bardstown, KY

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Us At:

ewco@ewco-ins.com

Phone: 1-502-348-5921
Fax: 1-502-331-0023
Toll Free: 1-800-999-5921

602 Bloomfield Road
Bardstown, KY 40004

KY Insurance License #:
611145

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Group Health Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!

Your Personal/Group Data:

Your Name:

Your Business Name:

Street Address:

City:

State: (Must be Kentucky)

Zip Code:

E-Mail (REQUIRED):

E-Mail again for accuracy:

Phone:

Fax (optional):

Group Details
(If more than 5 in group, contact us at: 1-800-999-5921)

Employee #1 Name

M/F

Age

Status

Occupation

Salary

Currently Insured?

Plan type

$

Employee #2 Name

M/F

Age

Status

Occupation

Salary

Currently Insured?

Plan type

$

Employee #3 Name

M/F

Age

Status

Occupation

Salary

Currently Insured?

Plan type

$

Employee #4 Name

M/F

Age

Status

Occupation

Salary

Currently Insured?

Plan type

$

Employee #5 Name

M/F

Age

Status

Occupation

Salary

Currently Insured?

Plan type

$

Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

Employee Health Problems?
(Do any of your employees have special health problems or insurance needs? If no, write "none".)

Group Plan Needs?
(Tell us what features you want in your group plan so that we may get the coverage and benefits you are looking for!)

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