Washington State Health Insurance, Michael Benzikry & Associates
Group Health Benefits Quote
Group Benefits
Individual Health
Short Term Medical
Dental Insurance
Disability Insurance
Life Insurance
Longterm Care
Group of employees
Company Information
*Required Fields
*Company Name:
*First Name:
*Last Name:
*Zip Code:
*Work Phone:
Alternate Phone:
*Best time to contact:
  Type of Company?
Do you currently have Business Group Health? No Yes
If yes, when does it renew?
Name of current carrier
Description of Business:
Number of Locations:
*Number of Employees:
Number of Employees currently covered:
Current Plan Information
  Type of Health Plan:
  Current Deductible: Other:
  Current Co-Insurance
  Office Visit Co-pay? No Yes If yes, co-pay amount
  Prescription Drug (RX)
No Yes If yes, co-pay amount
  Dental Plan
in place?
No Yes
Want Dental?
Yes No
  Vision Plan
in place?
No Yes
Want Vision?
Yes No
  Section 125, Cafeteria or Premium Only Plan in place? No Yes  
  Voluntary Benefits (employee paid) in place? No Yes
Want Voluntary Benefits?
Yes No
  Employer Contribution Percentage for Employees? Other:
  Employer Contribution Percentage for Employee Dependants? Other:
  Additional Comments or Questions?

Thank you for your inquiry!



Michael Benzikry & Associates, 9311 SE 36th Street #105, Mercer Island WA 98040 | Call (206) 232-1080
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