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Your Local Healthcare Benefits Specialist

Dave Burlew

Northern Michigan
Health Plans

Thompsonville, MI 49683
1-888-546-3460
9 am - 8 pm
Monday - Saturday

Offering the best health insurance options for Individuals, Families, Employer Groups, Seniors, Life, Disability and International Plans.

Email Dave For More Information

Employer Group Proposal Request

Complete the form below and press the Submit Proposal Request button at the bottom. An agent will contact you with your quote. Please be assured that your information will be kept strictly confidential in accordance with our privacy policy, and will not be sold for any purpose.

Company Information
Contact Name:
A name is required.
Business Name:
Type of Business:
Address:
An address is required.
City:
A city is required.
State:
Please select a state.
Zip Code:
A zip code is required.
County:
A county is required.
Email:
An email is required.
Phone Number:
A number is required.
Best time to call:
Fax Number:
# of Employees you wish to insure:
# of Full-Time Employees working over 30 hours:
Current Company Group Plan
(If your company does not currently have a health plan, please skip this section.)
Please indicate the type of health plan:
Traditonal PPO Network
HMO Plan HSA Plan
HRA Plan Other
 

Current Company:
Current Monthly Premium:
Doctor's Office Co-Pay:
Prescription Co-Pay or % (generic):
Prescription Co-Pay or % (brand):
Deductable Amount:
After the Deductable:
Vision?
Dental?
Disability?
Life?
Comments: