Small Group Health

Fill in the information below and click “submit” and a member of the Cecy Insurance Team will be in touch with you promptly about coverage for your small group. If you have any questions, please do not hesitate to contact us.


Company Name:
Contact Name*:
Office Phone Number*:
Fax Number:
Email Address*:
Mailing Address:
City, State, Zip

Employee Information:

Name Gender Home Zip Date of Birth Dependents to Insure Have Other Coverage?
MM DD YYYY Spouse Children Group? Individual?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

 

Does your company currently have a
health insurance carrier?:

Yes

No
If yes, which carrier do you have?:
Please provide the plan type:
When would you like this plan to start?:

* = required information