Freedom Insurance Agency, L.L.C.

"Our Family Caring for Your Family"

Group Health

List all eligible employees. All information received is kept fully confidential and is used for quoting purposes only.

Your Company Information

Note: This number would include part-time and seasonal personnel along with any other employees who are not eligible for or do not choose to take the insurance.

At this time If you have more than three employees add the information for the additional employees in the comments at the bottom of this page.

Employee Information (Please provide each Employee's information regarding the following)
Employee Name Gender Date Of Birth OR Age Providing Coverage For # Of Children
Employee Name Gender Date Of Birth OR Age Providing Coverage For # Of Children
Additional Comments