Be assured that all information you provide here is secure. Please reference our Privacy Policy for more information on our commitment to using information provided here strictly in conjuction with obtaining health insurance.

Request For Group Medical Insurance Quote

Business Name::(required)

 

Fax #:

 

 

Name of primary contact::(required)

 

Email:(required)

 

 

Phone #:

 

         

Street Address:

 

 

City

 

State :

 

   

Zip:

 

County:

 

 
How did you hear about Pallay Insurance Agency?:
 (examples: Association Name, Google, Yahoo, Bing, etc.)
 
 

Current Coverage

Current Carrier:

 

 

 

 

Anniversary Date:

 

Life Schedule:

 

Deductible:

 

Disability:

 'Y or 'N'

 

Co-Insurance:

 

Dental:

 'Y or 'N'

 

Out of pocket Maximum:

 

         
 

Comments: [ Any additional information ]

 
 

 

 
   
   
   

Employee Information

 Total Number of Employees:    

 

 Total Number of Employees Requesting Medical Insurance:    

 

 For each of the Employees Requesting Medical Insurance, please complete the information below:

 

Employee

Home Zip Code

Gender M / F

Date of Birth
Mon/Day/Year

Smoker Y / N

Coverage

Spouse Date of Birth
Mon/Day/Year

Spouse Smoker Y / N

Gender & Date of Birth
of Children

1

 

 

2

 

 

3

 

 

4

 

 

5

 

 

6

 

 

7

 

 

8

 

 

9

 

 

10

 

 

Comments: [ Any additional information ]  

                   


Other Information

SIC Code or Nature of Business:

 

Is everyone covered by Workers Compensation?

 'Y or 'N'                            


       

       
 

Upon submitting your request for a Group Insurance Quote, an email will be sent to Pallay Insurance.  You will be taken to a "Success" page after completing transmission.

Thank you for your request!
 

Note: This information will not be used for any other purpose except to generate a quotation for insurance. Any quotations generated are for your information only and are intended to be rough estimates. Actual quotations will only be issued after more complete information has been gathered, which will be made easier by completing this form. For any questions, do not hesitate to call us at 708.478.7499.

Pallay, Janich & Pryor, Inc. Home
 
 
 
 
 
 
 
 
 

Contact Us

Pallay Insurance Agency
P.O. Box 727
Mokena, IL 60448

Phone:
708.478.7499


 PALLAY INSURANCE AGENCY, INC.  

"e-Commerce with the personal touch"