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Allen/Freeman/McDonnell Agency

will be happy to quote your

GROUP HEALTH, LIFE, DENTAL, AND DISABILITY INSURANCES.

Be advised that we are only licensed to provide insurance in Maine. We no longer have a provider of Individual Health Insurance and recommend you call Anthem BC/BS directly at 1-800-541-4251.

For International Health and Travel Insurance, click this link.

For Short Term Medical Insurance, click this link.

Group Benefits

For Group Health, which includes group life, disability, dental and long term care, please answer each question that follows and then send the form to us over the net. We will contact you within two business days. There have been massive changes in the companies offering health insurance in Maine and you would likely do better by calling us at 1-800-762-8600 between 8-4:30 M-F. Thank you for considering

Allen/Freeman/McDonnell Agency.

Note: Items with an asterick (*) beside them indicate a question that must be answered to receive a quote.

Information About Your Company
Your Company Name:*
Contact Person:*
Address:*
City:* State:* Zip Code:*
Phone:* FAX: E-Mail:*
Number of Employees:*
TYPE OF COVERAGE REQUESTED Group Health Group Life Group Dental Group Disability Income
How do you wish to be contacted?

Present insurance company:		For How Long:	yrs
Policy Renewal Date:

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Allen/Freeman/McDonnell Agency

or its parent company, Insurance Made Easy©, Inc. does not resell or distribute your personal information in any form. We use the information from this form exclusively to try to provide you the insurance coverages which you are requesting. In completing this form, you give us premission to telephone you,if needed.