Group Health Plan Quote Request, Moran Insurance Group

Contact Information

Contact Name *

Contact name is required

Email *

Valid email is required

Phone

Title / Role

Business Information

Business Name *

Business name is required

Tax ID (EIN)

Street Address

City

State

ZIP Code

SIC Code (Industry)

Number of Employees *

Number of employees is required

Plan Request Details

Requested Effective Date

Current Carrier (if any)

Current Monthly Premium (if known)

Renewal Date (if applicable)

Requested Plan Type(s) *

HMO

POS

PPO

HDHP

Please select at least one plan type

Employer Contribution

Enter a percentage of premium (e.g. 50%) or a flat dollar amount per employee, per month (e.g. $300). Pick %/$ for each.

Employee Contribution *

Enter a valid employee contribution (0 to 100%, or a dollar amount)

Family Contribution

Enter a valid family contribution

Carrier Preferences

Which carriers would you like to see? (Select as many as you prefer)

Coinsurance Options

Select up to 2 coinsurance levels you'd like to see

0 of 2 selected

Optional Ancillary Benefits

Would you like quotes for additional coverage?

Dental

Vision

Life Insurance

Short-Term Disability

Long-Term Disability

Employee Census

Add each employee who will be enrolled. You can also add their spouse and/or dependents.

Additional Notes

Anything else we should know?

Employer Census Certification

To be completed and signed by an authorized representative of the employer

Employee Count Certification

An “eligible employee” is any common-law employee who meets your eligibility requirements for group health coverage (e.g., full-time status, waiting period satisfied).

Total W-2 Employees (all classes) *

Required

Total Eligible Employees

Employer Certifications

By signing below, I certify and acknowledge the following:

The employee census provided to Moran Insurance Group LLC is complete and accurate and includes every eligible employee of the company as of the date of this certification. No eligible employees have been omitted.
I understand that the insurance carrier will rely on the accuracy of this census to determine the group’s eligibility for coverage, premium rates, and compliance with minimum participation requirements.
I understand that the carrier requires a minimum participation rate (typically 70% of eligible employees, excluding valid waivers) and that failure to meet participation requirements may result in denial of coverage, policy rescission, or non-renewal.
I understand that intentionally omitting eligible employees from the census, misrepresenting employee counts, or misclassifying employees to manipulate participation rates constitutes material misrepresentation and may result in rescission of the group policy by the carrier.
I agree to promptly notify Moran Insurance Group LLC of any changes to the employee census, including new hires, terminations, or changes in eligibility status, within 30 days of such change.
I acknowledge that Moran Insurance Group LLC is relying on the accuracy of the information I have provided in submitting this group’s application to the insurance carrier, and that Moran Insurance Group LLC is not responsible for verifying the employer’s payroll records or conducting an independent audit of eligible employees.
I understand that if the carrier determines that the census was inaccurate and the group does not meet eligibility or participation requirements, any resulting policy rescission, denial, or penalty is the sole responsibility of the employer and not Moran Insurance Group LLC or its agents.

Print Name *

Required

Title *

Required

Signature *

Sign here

Date

I have read and agree to the certifications above *

By submitting this form, you consent to receive SMS messages and phone calls from Moran Insurance Group regarding your insurance inquiry. Message frequency varies. Message & data rates may apply. Reply STOP to opt out. Terms & Privacy Policy.

Group Health Plan Quote Request

Quote Request Received!