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Group Health Insurance Quote Form

Contact Info & Consent

Business Name *

Contact Name *

Email *

Phone *

State *

(helps route based on state + carrier availability)

Postal Code *

I consent to be contacted by phone, email, or text by Fortune Shield Insurance Agency (or its representatives) about insurance products and services, including health and employee benefit plans. I understand that my consent is not a condition of purchase and that I may opt out at any time.

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Group Basics

How many full-time employees need coverage? *

How many part-time/1099s?

Target Start/Renewal Date

Coverage Needs & Priorities

What’s most important to your business? *

Affordable rates

Attracting/retaining employees

Comprehensive coverage

Flexibility for part-timers

Are you interested in exploring alternative or level-funded plans?

Yes

No

Unsure

Next Steps

Census upload optional

Optional (Excel/CSV) - please remove any Social Security Numbers or private medical details

Fortune Shield Insurance Agency is a licensed independent insurance agency. Not all products are available in all states. Eligibility and benefits vary by carrier and state. Information provided is for quoting and educational purposes only.

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Fortune Shield is a licensed independent insurance agency. Not all products are available in all states. Eligibility and benefits vary by carrier and state. Enrollment subject to approval. Fortune Shield is not connected with or endorsed by the U.S. government or the federal Medicare program.