Group Insurance Information Request Form

Please complete all pertinent information and hit the "submit" button at the
bottom of this page to automatically email this information to GBS.

* indicates a required field

Group Information

Contact Name:

 *
Referred by:
Company: *
Street Address: *
City, State, ZIP: * , * , *
Phone Number: *
Fax Number:
e-mail address:
Type of Business:
Number of Employees:
Plan Types (select all that apply):
Medical Dental Vision COBRA
Section 125 Life Disability 401K
Deductible Amount:
Request Effective Date:
Are you interested in a Prescription Drug Card?

Are you interested in maternity benefits?

Please describe current
coverage benefits including insurer name and rates:
Additional Comments:
We also need you to complete a medical history questionnaire. However, HIPAA regulations prevent this information from being collected over the web, so please download and complete the Employer Claims Data form and fax it to us at 512.533.9946.

Census Data Upload

In order to be able to quote rates, we will also need a census of the members of your group.    Please use this form to upload a spreadsheet that contains your census data. If you already have this information in another format, please feel free to upload that file instead. 

Uploading the census at this time is optional, but we will require this information before we can issue a quote of any kind.

 
 

  We provided this blank spreadsheet for your convenience as use as a template.  Click on this icon to download.  Complete one line for each group member, and then upload it using this form.  You must give your file a unique name that contains no spaces.

 

Location of your census file:

     

 

Insurance : Administrative Services : HSA Admin : Associations
HIPAA Information : Forms Repository : About Us
 
Corporate Headquarters
8716 North MoPac Expy
Suite 200 Austin, Texas 78759
toll free -  1.800.822.4017
telephone -  512.533.9936
fax -  512.533.9946
Licenses: 646937, 11778
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