New York Employee Health Insurance Quote

**Information received from this NY, CT, or NJ Group Health Insurance quote

request 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 group health insurance plan 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 an Employee Health Insurance Plan Policy. We are licensed in New York, Connecticut,

and New Jersey and will not provide group health insurance quotes for other states.

We offer New York group health insurance quotes for small business 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 insurance benefits to employees?
Group Health Insurance Coverage For:
How many employees to be insured:

HMO Group Health Insurance   HMO Co-Pay Amount Desired:
PPO Group Health Insurance     PPO Deductible Amount Desired:
POS Group Health Insurance     POS Co-Pay Amount Desired:
Fee-for-Service Insurance          Fee-for-Service Deductible:

Choose Benefit Options:
Group Dental Insurance Coverage:
Group Vision Insurance Coverage:
Group Life Insurance Coverage:

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 Group Health insurance quote request.**

We also offer affordable Connecticut group health insurance quotes 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.