HOME ABOUT US FOR CLIENTS RESOURCES INSURANCE LINES QUOTES CONTACT US Home > Forms > Group Health Group Health Insurance Quote Request Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office. I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. General Information First Name* Last Name* Address* City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code* Home Phone Cell Phone Email Address Best Time to Contact 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00pm 2:00pm 3:00pm 4:00pm 5:00pm 6:00pm 7:00pm 8:00pm Contact By Home Phone Cell Phone Email Number of Employees Please Quote PPO HMO Both Include Dental Yes No Current Policy Information Agent Address City Policy Expiration Date Additional Information In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages engines, etc. Employee Information Employees Name Age Gender Male Female Family Coverage Yes No Add Employee Where Are We? 9455 Koger Blvd N #100 St. Petersburg, FL 33702 Ph: 877.469.4942 Ph: 727.530.0684 Fax: 727.532.9602 Resources 4JacksHelp FAQs Policy Definitions 24/7 Client Portal Useful Links Pay Now Insurance Lines Business Insurance Employee Benefits Life Insurance Personal Insurance Quotes Quotes Automobile Quote Business Insurance Quote Business StormPeace Cyber Insurance Quote Homeowner Quote Flood Insurance Quote Group Health Quote Life Insurance Quote Personal StormPeace Facebook Jack Rice Insurance Privacy Notices Terms of Agreement and Usage © 2021 Jack Rice Insurance. All rights reserved. No portion of this site may be reproduced in any manner without the prior written consent of Jack Rice Insurance. Jack Rice Insurance is committed to making its website usable by all people by meeting or exceeding the requirements of the Web Content Accessibility Guidelines 2.0 Level AA (WCAG 2.0 AA). Jack Rice Insurance has conducted an accessibility review of its website and has remediated any issues identified during that review. Please be aware that our efforts are ongoing as we incorporate the relevant improvements to meet WCAG 2.0 AA guidelines over time. If you have specific questions or concerns about the accessibility of this site or need assistance in using the processes found within this site, please contact us at (877) 469-4942. If you do encounter an accessibility issue, please be sure to specify the page and we will make all reasonable efforts to make that page accessible. For further inquiries please reach out to Cynthia Webster (877) 469-4942.