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Nevada Direct Quote

Group Health Insurance

Complete the following information if you would like a free, no-obligation quote for life or disability insurance. (You will not be called unless requested)

Email Phone Fax Postal Mail
Company Name
Contact Name
Business Address
Phone Number
Fax Number
Email Address
Business Start Date
City
Nevada Zip Code
How did you hear about us?
Does the company have offices in any other state? yes no
If yes, what states?
Nature of your business?
Does the business have a business license? yes no
Do you file a quarterly wage and tax report for all W-2 employees? yes no
Who is your current health insurance carrier?
Requested effective date for your new plan:
Which plans are you interested in? HMOs PPOs All Plans

Which Options are you interested in?
Prescription Drug Card	Long-Term Disability
Dental	Group Life Insurance
Maternity	Pension Planning
Employee 1
male female	Date of Birth
Spouse's Age	No. of Children
Employee 2
male female	Date of Birth
Spouse's Age	No. of Children
Employee 3
male female	Date of Birth
Spouse's Age	No. of Children
Employee 4
male female	Date of Birth
Spouse's Age	No. of Children
Employee 5
male female	Date of Birth
Spouse's Age	No. of Children
Is any employee or dependent now pregnant? yes no
Does any employee or dependent have any health problems or has anyone had surgery in the last 3 years? yes no
If yes, please describe:
Is any employee or dependent taking any medications? yes no
If so, what condition is the medication for and what is the dosage?

Las Vegas 702-258-1995

Reno 775-329-1995

Authorized
Representative

Brochure | Application

Las Vegas | Reno

Short Term Medical Plan

Las Vegas | Reno

Las Vegas | Reno | Reno SDHP

Las Vegas | Reno

Anthem Dental

Las Vegas | Reno

Low Rates Guaranteed
Nevada Direct Quote does not charge you a fee for any of our services. Since Health Plans are regulated in Nevada, no one else can offer you a lower premium!