Non-Traditional Plan Quote

Non-Traditional Health Plan Quote (for W2 / 1099 Employees (if desired))

Tell Us About Your Company or Non-Profit

Name *

First

Last

Email *

Phone *

Company Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Company Business Structure

When is Your Plan Renewal Date (if applicable) or Potential Start Date?

Do You Have Employees in Multiple States? *

Do You Have 1099 Employees? *

Would You Like Quotes for? *

Please Note: If you only want 1099 Employees quoted please place a N/A in the required W2 Employee number sections.

# Employee-Only *

(The number of W2 employees who do not have dependents included on their current healthcare plan)

# Employee+Spouse *

(The number of W2 employees who have a spouse included on their current healthcare plan

# Employee+Child *

(The number of W2 employees who have 1 or more children included on their current healthcare plan)

# Employee+Family *

(The number of W2 employees who have a spouse and 1 or more children included on their current healthcare plan)

1099 Employee Ages

Please break down the # of 1099 Employee(s) into the following Age Brackets: 18-29 | 30-49 | 50-64

Would You Like Quotes from? *

Please Note: We recommended HIPnation for Atlanta-area businesses and Health Access Solutions for other U.S. locations (and Atlanta) (or if you have locations across multiple states).

Upload Your Employee Census Here (optional)

Click or drag files to this area to upload. You can upload up to 5 files.

For the most accurate quote, upload an up-to-date census, which should include all names, zip codes, and the date of birth for each employee and any dependents. Download an Employee Census Form at: https://owneronlybenefits.com/employeecensus

Additional Comments