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)

Drag & Drop Files, Choose Files 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