Group Coverage Quote Form

To receive a free quote for group insurance, please complete the following form or call us at 303-442-1000 or 800-887-0054.

Please select the types of coverage you are interested in:
Health
Life
Disability
Dental
Vision
HRA's
FlexWise
Retirement Plans

Please complete the following information:

Name
Company
Nature of Business
How long have you been in business?
Address
City
State ZIP
Phone
Fax
Email

Do you currently have a group plan? Yes No
If yes, who is your current carrier?
What type of plan do you have? Please give as much information as possible.

What are your current/renewal rates?
When does your current plan renew?

Please complete the following census: (If over 10 employees, please fax the census to 303-449-0243)

Employee 1 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

Employee 2 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

Employee 3 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

Employee 4 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

Employee 5 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

Employee 6 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

Employee 7 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

Employee 8 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

Employee 9 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

Employee 10 Date of Birth (mmddyyyy)
Gender: M F
Status Select One Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
Hours worked per week

How did you hear about us?

Comments/Other

Thank you for your interest in Hofgard & Company!