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  Individual or Group Health & Life Application  
   
* Indicates Required Information  | Your information is protected, see our privacy policy.
Company Information / Personal Information
* Comapny name (if individual put NONE)
* Phone number (daytime)
ex: xxx-xxx-xxxx
* Your First Name Phone number (evening)
ex: xxx-xxx-xxxx
* Your Last Name * E-mail Address
* Address * Industry
* City * Company Size
* State    
* Zip    
Coverage Information
Note: The number of employees you enter should reflect only the number of employees covered under the plan and should not include any spouses or dependents.
Please enter the total number of employees, including yourself, to be covered by this health insurance plan.
(Answer with numbers only -- e.g., 4, not four.)
Do you currently have an insurance carrier? (specify carrier and expiration) No
Yes (carrier/expiration):
What types of health insurance do you currently offer?
What types of health insurance would you like? (check all that apply)
HMO Traditional insurance
PPO Not sure
Point of Service (POS) Other (please specify):
Self insure
What types of coverage do you want?
(check all that apply)
Medical Dental
Prescription drug plan Life
Vision/eyewear Wellness programs
Mental health  
When do you need your health plan to take effect?
What percentage of the premium will your company cover? 
What maximum deductible do you prefer?
Do you have employees that live outside of your business's state?  No
Yes (specify states):    
How many years has your company been in business?*
What is the five digit ZIP code for your office location?
Please describe in detail any additional requirements you may have.

Note: There is a 500 character limit for this answer.
Employee Census
*Please note: If you have greater than 10 employees, Horst Insurance will be contacting you for the census information.
If 10 or fewer employees or if this is an individual quote, please complete the following census for each person, indicating sex, age and type of coverage needed.
Sex Age Coverage Home Zip Code
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Reset
Insurance products are not available in every state. ABI Insurance Agency is not licensed in every state. Restrictions may apply. Nothing on this application constitutes a policy, binder or agreement to provide coverage. All applicants must meet underwriting requirements.