Health Associates, LLC - Brokers - Agent Information Form

The following form may be emailed upon completion.

Brokers:

Name:

Address:

Telephone Number:

Louisiana Insurance Agents License Number:

Number and Size of Health Insurance Cases (Actual or Estimated) Per Year:

25 lives 50 lives 100 lives More

Client Information:

Client Name:

Location of Client Headquarters:

Are there any other service locations, if so, identify:

Number of full time employees:

Number of part time employees:

Present health insurance provider:

Type of Health Plan:
Indemnity PPO HMO Other

Benefits:
Mental/Nervous
Alcohol & Drugs

Does employer have union employees?

Does the client currently have an EAP? Yes No

If yes, name of EAP

Optional Information:

Percentage of female employees:

Percentage of male employees:

Percentage of employees enrolled in health insurance plan:

Percentage of premium paid by employer for the employee:

Percentage of premium paid by employer for the family:

Current individual premiums:

Current family premiums: