Group benefits insurance information request

Complete and submit this form to have a representative connect with you about Humana Group Benefits insurance.

Campos obligatorios

1. Díganos de usted

Nombre
Número de teléfono
Correo electrónico

2. Tell us about your company

Nombre de la empresa
Número de teléfono
Headquarters address
Cantidad total de empleados
Total number of W-2 employees

3. Tell us about your insurance needs

¿Qué tipo de cobertura le interesa?
Planes dentales
Planes de la vista
Planes de vida
Cobertura por incapacidad a corto plazo
Cobertura por incapacidad a largo plazo
Coverage Start Date: mm/dd/yyyy
Do you currently offer group coverage?
Planes dentales
Planes de la vista
Planes de vida
Cobertura por incapacidad a corto plazo
Cobertura por incapacidad a largo plazo
No
If so, who is your current carrier?
Are you currently working with a broker?
No
Broker/Agency name:
Our agent will need a census for quoting. Can you provide a census when the agent reaches out to you? A census includes the names, dates of birth, genders and home ZIP codes of the employees (and their dependents) who need coverage.
No