Friends Referring Friends Since 1912
500 West Turkeyfoot Lake Rd., Akron, Ohio 44319
Phone: 330.644.6300 Fax: 330.644.5548
Group Health Quote Form
Group Name:
Group Contact:
Group Address:
Group Phone:
Group Fax:
Current Health Carrier
Carrier Contact:
# of Employees:
Effective Date:
How long in business:
Cobra Employees:
Employees in waiting period:
Worker's Compensation?
Census
Name
Age
Dependent Status
Zip Code
Waiving
