Minnesota Health Insurance

Minnesota Health Insurance Network

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Minnesota Small Group Health Information Request

This is a request for a quote, not a policy application. Submitting this form does not obligate you to purchase any products. Please complete this form as accurately as possible. Insurance rates are subject to change.

Required*

Contact Name*
Company Name*
Address*
City*
State*
Zip*
E-mail*
Phone*
General Information
Total number of Employees*
Approximate Number of Employees participating*
Employer contribution toward Employee Cost*
If Other:
Type of Entity:*
Current Health Care Carrier
If Applicable
Renewal Date
If Applicable
Employee Census

The Employee Name is optional, Employee DOB is mandatory, Spouse's DOB must be included if requesting coverage, Children's ages must be included if requesting coverage and should be separated by commas

Employee

Name

Employee

DOB

Spouse

DOB

Dependent Children

Ages

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Add Another Employee

Additional Comments

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