Health Insurance – Shopping Form

Health Insurance Shopping Form

We’ll quote multiple carriers for you.

Moran Benefits - Online Quote form

Are you interested in individual or group coverage?(Required)

A group plan covers employees of a business; an individual plan covers just you and your family

Group

Individual

Group name

Your Name

First Last

Your Email Address

Address

Street Address Address Line 2 City State ZIP Code

Business Codes

NAICS: North American Industry Classification System SIC: Standard Industrial Code Don't know yours? NAICS Search and SIC Search

NAICS Code

SIC Code

Current Insurance Carrier(s)

Current Renewal Date

Number of Employees Eligible

Number of Employees Enrolled

You can enter employee data in the chart below by clicking the 'Add Employee' button and following the prompts. OPTIONAL: If you would rather send us employee data via excel spreadsheet click to download our template file. After completion, use the 'Select File' button below to upload your completed census template.

Employee Details

Employee Name

DOB

Gender

Enroll/Waive

Zip

Spouse DOB

# of Children Enrolling

Children #1 DOB

Children #2 DOB

Children #3 DOB

Children #4 DOB

More details

Name

Self/Partner/Dependent

DOB

Gender

Zip

Upload your census file here

See directions and template above.

Drop files here or

Accepted file types: xlsx, csv, Max. file size: 32 MB.

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