HIPnation Quote

Tell Us About Your Company

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?

# Employee Only *

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

# Employee+Spouse *

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

# Employee+Child *

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

# Employee+Family *

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

Do You Have 1099 Employees? *

# 1099 Employees

How many 1099 Employees do you have?

Would You Like to See Benefit Options for Your 1099 Employees?

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