Webster Insurance Agency Inc

Webster Insurance Agency Inc. · 200 South Bellevue Avenue · Langhorne PA 19047 · 215-757-0816

Small Business Health Insurance Quote Form

This submission is a request. Insurance coverage changes and new coverage are not effective until we confirm that for you.

We will personally respond to you the same business day you submit this request if it is submitted by 4:00 p.m. If it is after 4:00 p.m. we will respond the following business day. Be sure to let us know what method of contact you prefer. Thank you for the opportunity to help you with your insurance protection.

Binding Agreement
I understand that any policy changes are effective only when I have received a written confirmation.
* Required Fields *I agree

Requestor Information *First Name: *Last Name:

*Email: * Phone Number: Fax:

*How should we contact you if we have follow up questions? Email Phone Fax

Quote Information Census Form

Group (Company) Name

Street Address

Address (cont.)

City

State: Zip Code:

Nature of Business/SIC Code

Requested effective date

Current Carrier

Check which Carriers you would like us to quote

Plan Type

Co-pay

Hosp. Co-Pay

RX Card

DOB= MM/DD/YYYY - Gender = (M) (F)- S= Single H/W= Husband/Wife P/C= Parent/Child F=Family
Child'n= #of Children - Zip = Home Zip Code - Waver = (Y) (N)

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