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Home  Employer Group  Get Quote Thank you for your interest in Hometown Health insurance. Please provide the following information below.  Proposal requests are generally done within 3 business days.   * Indicates required information Company Name  Contact Name *  Email Address *  Street Address 1 *  Street Address 2  City *  State *  AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Zip *  Phone 000-000-0000 *  Business Type or SIC code *  Years in Business *  Requested Effective Date *  January 1st February 1st March 1st April 1st May 1st June 1st July 1st August 1st September 1st October 1st November 1st December 1st Total # of Employees *  Total # of Eligible Employees *  Total # of Cobra Active Employees *  Total # of Cobra Pending Employees *  Employer Premium Contribution % *  50% 75% 90% 99% 100% Current Carrier *  Number of Years with Carrier *  Current Benefit Design *  HMO PPO POS EPO HSA Don't Know Current Rates  Current Renewal  Requested Plans to be Proposed *  HMO PPO HSA Requested Co-Pay Amount HMO  $10 $15 $20 $25 $30 $35 $40 $45 $50 Requested Hospital Copay Per Day (5 days Max) Amount HMO   $0 $50 $100 $150 $200 $250 $300 $350 $400 $450 $500 $750 Requested Hospital Copay per Admit Amount  $0 $50 $100 $150 $250 $300 $350 $400 $450 $500 $750 $1000 $1250 $1500 $1750 $2000 Requested Copay PPO  $10 $15 $20 $25 $30 $35 $40 $45 $50 Requested PPO Deductible   $250 $500 $750 $1000 $1250 $1500 $1750 $2000 $2250 $2500 $2750 $3000 $3250 $3500 $3750 $4000 $4250 $4500 $4750 $5000 Requested HSA Deductible   $1150 $1500 $2000 $2500 $3000 $3500 $4000 $4500 $5000 HMO Rx Copay  05/10/($10) 05/15/($25) 10/30/($50) 15/45/($50) 15/40/($60) 20/60/($120, 40%) Other If Other, please specify: PPO Rx Copay  05/10/($10) 05/15/($25) 10/30/($50) 15/45/($50) 15/40/($60) 20/60/($120, 40%) Other If Other, please specify: Dental Option *  Yes No Vision Option *  Yes No Employee 1 Gender  Male Female Employee 1 Age  Employee 1 Spouse  Yes No Employee 1 # Children  Employee 2 Gender  Male Female Employee 2 Age  Employee 2 Spouse  Yes No Employee 2 # Children  Employee 3 Gender  Male Female Employee 3 Age  Employee 3 Spouse  Yes No Employee 3 # Children  Employee 4 Gender  male Female Employee 4 Age  Employee 4 Spouse  Yes No Employee 4 # Children  Employee 5 Gender  Male Female Employee 5 Age  Employee 5 Spouse  Yes No Employee 5 # Children  Employee 6 Gender  Male Female Employee 6 Age  Employee 6 Spouse  Yes No Employee 6 # Children  Employee 7 Gender  Male Female Employee 7 Age  Employee 7 Spouse  Yes No Employee 7 # Children  Employee 8 Gender  Male Female Employee 8 Age  Employee 8 Spouse  Yes No Employee 8 # Children  Employee 9 Gender  Male Female Employee 9 Age  Employee 9 Spouse  Yes No Employee 9 # Children  Employee 10 Gender  Male Female Employee 10 Age  Employee 10 Spouse  Yes No Employee 10 # Children  Employee 11 Gender  Male Female Employee 11 Age  Employee 11 Spouse  Yes No Employee 11 # Children  Employee 12 Gender  Male Female Employee 12 Age  Employee 12 Spouse  Yes No Employee 12 # Children  Employee 13 Gender  Male Female Employee 13 Age  Employee 13 Spouse  Yes No Employee 13 # Children  Employee 14 Gender  Male Female Employee 14 Age  Employee 14 Spouse  Yes No Employee 14 # Children  Employee 15 Gender  Male Female Employee 15 Age  Employee 15 Spouse  Yes No Employee 15 # Children  Employee 16 Gender  Male Female Employee 16 Age  Employee 16 Spouse  Yes No Employee 16 # Children  Employee 17 Gender  Male Female Employee 17 Age  Employee 17 # Children  Employee 17 Spouse  Yes No Employee 18 Gender  Male Female Employee 18 Age  Employee 18 Spouse  Yes No Employee 18 # Children  Employee 19 Age  Employee 19 Gender  Male Female Employee 19 Spouse  Yes No Employee 19 # Children  Employee 20 Gender  Male Female Employee 20 Age  Employee 20 Spouse  Yes No Employee 20 # Children

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