Alliance Insurance Brokerage, LLC

PRODUCTS & SERVICES

Alliance Insurance Brokerage, LLC

Group Health Insurance

We provide insurance to small,medium and large companies. Because every group is different, we take the time to find the right plan for your group. We carry the top companies in Kansas and Missouri for Group Health Insurance. Please submit the form below and let us start shopping for you today.

Group Health Insurance

Company Information:
Legal Name of Business:
Contact Name:
Address:
City:
State
Zip:
Business Phone:
Best Time To Call:
E-Mail:
Nature of Business:
Type of Business:
Standard Industry Code (if known):
# of Full Time Employees::
# of Part Time Employees:
Give a complete description of any hazardous or dangerous duties performed by your employees:
Current Group Health Benefits:
Carrier (Company) Name (not agency):
Please give a brief description of your current Group Health plan:
Benefits Desired:
Major Medical Deductible: Optional Pregnancy Coverage:
Dental Coverage: Supplement Accident Coverage:
Disability Insurance:

PCS Card:
(Prescription Discount Option)
Group Life Insurance:

PPO Option:

HMO Option:
Please list all employees you wish to cover:
**You may also email your companies census in a text, delimited or excel file.
Employee Name:
Date of Birth:
Gender:
Dependent Status:
Employee Name:
Date of Birth:
Gender:
Dependent Status:
Employee Name:
Date of Birth:
Gender:
Dependent Status:
Employee Name:
Date of Birth:
Gender:
Dependent Status:
Employee Name:
Date of Birth:
Gender:
Dependent Status:
Employee Name:
Date of Birth:
Gender:
Dependent Status:
Employee Name:
Date of Birth:
Gender:
Dependent Status:
Employee Name:
Date of Birth:
Gender:
Dependent Status:
Additional Comments
If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or email an additional listing.
**You may also email your companies census in a text, delimited or excel file.