Group Health

We offer a variety of competitively priced policies we can tailor to your company and employee needs. For a quote on small group insurance please fill out the form below with the most current information for EACH employee.

Company Name *

Company Phone Number *

Company Fax Number *

Address *

City *   State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code*

Business Type*

Are you a member of any chamber of commerce ----------- Yes No

Current health insurance provider*

Current health insurance plan*

Number of employees covered under spouse insurance or declining insurance*

Total number of full time employees*

Please list each employee, sex, date of birth, family status (1-single, 2-Emp+spouse, 3-Emp+children, 4-Family) number of covered children and ages*

Form completed by*

The Insurance Source GA | Gary Reynolds and Associates INC 332 Washington St. NW | 206 Gainesville, GA 30501 Phone: 770-532-1900 | Toll Free: 1-877-532-4279 Fax: 770-532-2174

Hours: Monday - Friday 9:00am-5:00pm Appointments from 10:00am-4:00pm