Group Plan Patient Form

Insurance plans of Florida is an independent agency representing all of the leading group insurance carriers for health, life, dental, vision and disability plans. We can provide companies who would like to control costs but maintain an attractive benefit package for their employees. Please fill out the following information so that we can assist you.

* Indicates a required field.

* Business Name:
* Contact Name:
* Email: (ie. you@yourdomain.com)
* Phone Number: (ie. 123-456-7890)
  Address:
  City:
State: Zip Code: (ie. 12345)
* Nature of Business:


  Current Insurance Company: Renewal Date:
        (MM/DD/YYYY)
Coverage Types:   HMO PPO POS Dental
(check all that apply)    


Complete census form for all employees participating in the health plan.
  Name Gender DOB or Age Spouse's Age # of kids Zip Code
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10


  Security Image:  Case Sensitive help? CAPTCHA (for Completely Automated Turing Test To Tell Computers and Humans Apart)
A CAPTCHA is a program that can generate and grade tests that humans can pass
but current computer programs cannot.
     
* Security Code:
Enter the text from the image above into this box.

   

 

Insurance Plans of Florida, owned and operated by Lovelace Insurance

Toll Free: 888.556.5859
Telephone: 561.845.7392
Fax: 888.556.5859
Email: info@lovelaceinsurance.com

PO Box 9117
West Palm Beach, FL 33419

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