NY Health Savings Account Quote

** Information received from this NY, CT, or NJ Health Savings Account quote form sent to

Direct Access Group Benefits will be for our use only and will not be sold, given to or distributed

to any other parties. A quote will be based on the health insurance information provided

and does not guarantee acceptance of the risk by us. The precise coverage afforded is

subject to meeting underwriting guidelines, and the terms, conditions and exclusions of

the policy as issued. By submitting this request you acknowledge that this is neither

an offer to insure nor a guarantee of insurance. Completion of this form does not

entitle you to a Health Savings Account. We are licensed in NY, CT, and NJ

and will not provide quotes for other states.

We offer affordable health savings account plans for businesses in the following
New York counties and cities: Westchester County, Putnam County, Orange
County, Rockland County, Port Chester, Harrison, Mamaroneck, Larchmont, New
Rochelle, Yonkers, White Plains, Rye Brook, Scarsdale, Rye, Ardsley, Hartsdale,
Bronxville, Mt. Vernon, Mount Vernon, Irvington, Valhalla, Elmsford, Dobbs Ferry,
Hastings on Hudson, Greenburgh, Tarrytown, Sleepy Hollow, Hawthorne,
Scarborough, Thornwood, Briarcliff Manor, Ossining, Harmon, Montrose, Crugers,
Buchanan, Peekskill, Millwood, Pleasantville Armonk, Chappaqua, North Castle,
Mt. Kisco, Bedford, Pound Ridge, Bedford Hills, Cross River, South Salem,
Yorktown Heights, Goldens Bridge, Amawalk, Yorktown, Katonah, Salem Center,
Somers, North Salem, Croton Falls, Jefferson Valley, Shrub Oak, Palisades, Sparkill,
Tappan, Orangeburg, Pearl River, West Nyack, New City, Nanuet, Chestnut Ridge,
Montebello, Suffern, Monsey, Spring Valley, Congers, Nyack, Rockland Lake,
Wesley Hills, New Hempstead, Pomona, Sloatsburg, Ramapo, Hilburn, Willow
Grove, Mt. Ivy, Thiells, Tomkins Cove, Ladentown, Haverstraw, Stony Point,
Tomkins Cove, West Haverstraw, Bear Mountain, Jones Point, Newburgh,
Middletown, and Poughkeepsie, NY.

Business Name:
Premises Address:
City:     State:     Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required)
Description of Operations or SIC code:

Current Insurance Company:
Policy Expiration Date:          (mm/dd/yyyy)

Do you currently offer Health Savings Account options to employees?
Want Health Savings Accounts For:
How many employees to be insured:

Has any employee to be insured experienced serious health
problems during the last 18 months?
If "Yes", please explain below.

Additional Information or Comments

Click on the "Submit Quote Information" button below to send
your NY, CT, or NJ Health Savings Account quote request.**

We also offer affordable health savings account plans for businesses in the following Connecticut counties and
cities: Fairfield County, Stamford, Norwalk, Greenwich, Darien, Riverside, Belltown, Springdale, Round Hill, Old
Greenwich, East Norwalk, New Canaan, Glenville, Byram, Cos Cob, Mianus, North Stamford, Glenbrook, Wilton,
Weston, Long Ridge, Noroton, West Norwalk, Westport, High Ridge, Southport, North Wilton, Winnipauk,
Cannondale, Turn of River, South Wilton, Lyons Plains, Georgetown, Ridgefield, Branchville, Redding, Topstone,
Ridgebury, Redding Ridge, Branchville, Dodgingtown, West Redding, Titicus, Hattertown, Bethel, Danbury, New
Fairfield, Newtown, Hawleyville, Botsford, Monroe, Bridgeport, Stepney, Shelton, Huntington, Upper Stepney, Long
Hill, Trumbull, Stratford, Easton, Fairfield, Greenfield Hill, Stratfield, Nichols, Oronoque, Rivercliff, Devon, Lordship,
and East Bridgeport, and New Haven, CT.