Submit - http://goexcelhealth.com

Email

sales@excelhealthplans.com

Phone

818-624-7600

Address

1607 Capitol Avenue, Suite 317
Cheyenne, WY 82001

Office Hours

Monday - Friday
8:00 AM - 6:00 PM MST

Group Submission Form

Submit the information needed to begin the quote process. Required fields are marked with red asterisks.

Broker Information

Broker's First Name *

Broker's Last Name *

Broker's Email *

Broker's Phone Number

Account Manager Information

Account Manager's First Name

Account Manager's Last Name

Account Manager's Email

Account Manager's Phone Number

Brokerage*

Group Information

Group Name *

Effective Date*

Requested Plan Contract Length*

Standard contract is 12/18 (12 months with a 6 month run out for stoploss). Custom contracts are available for larger groups.

Street Address*

City*

State*

Zip Code*

Standard Industrial Classification *

Eligible Lives *

Enrolled Lives *

Requested Commission * $

Commission is calculated as a PEPM amount. If left blank, the standard $35.00 PEPM applies.

Quote Due By Date*

Current Insurance Information

Current Insurance Type

Current Insurance Carrier

Current Network

General Agent Information

General Agency

General Agent's First Name

General Agent's Last Name

General Agent's Email

General Agent's Phone Number

Submitted Data

Confirm which data is being submitted. Required data is marked with a red asterisk.

Census Data *

Current Rates *

Renewal Rates *

Current Plan Designs *

Experience Data

File Upload

Census (First Name, Last Name, Relationship, Tier, Gender, State, and Zip Code), Experience Data, Current Plan Designs, Current and Renewal Rates. .ZIP Files are the easiest method of submission.

Reason for Quote Request

How did you hear about us?

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Email

Phone

Address

Office Hours

Group Submission Form