Group Benefits Application

This application has been designed to gather all the information we need to prepare a complete insurance proposal for you, not just a premium “estimate.”

* Indicates Required Information  | Your information is protected, see our privacy policy

Company Information













Coverage Information

Note: The number of employees you enter should reflect only the number of employees covered under the plan and should not include any spouses or dependents.









Employee Census

Please note: If you have greater than 10 employees, Horst Insurance will be contacting you for the census information.

If 10 or fewer employees will be enrolled in the group health plan, please complete the following census for each employee, indicating sex, age, type of coverage needed and the employee's home zip code.

Sex
Age
Coverage
Home ZIP Code



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Insurance products are not available in every state. Horst Insurance is not licensed in every state. Restrictions may apply. Nothing on this application constitutes a policy, binder or agreement to provide coverage. All insurance is provided through H.G.I.D., Inc., t/a Horst Insurance. All applicants must meet underwriting requirements.