GREAT RATES

LOW COST HEALTH INSURANCE

NOW ELIGIBLE	1 Person Groups, Self Employed,
	Sole Proprietors, 1099 Employees!
	Also: Groups of 2 - 50 Employees.

MONTHLY RATES	$275	Single
	$549	Employee/Spouse
	$553	Employee/Children
	$701	Employee/Spouse/Children

PLAN BENEFITS

$25

$500

20/30/40

OFFICE CO PAY

HOSPITAL CO PAY

Rx Plan

Fax To (631) 543-5369

Please Print

Company Name:

Company Address:

Contact Name:

Title:

Phone:

FAX:

E-mail:

Current Medical Insurance Company

# of Employees Covered under Plan

Anniversary Date

Company Name:
Company Address:
Contact Name:
Title:
Phone:
FAX:
E-mail:

Current Medical Insurance Company
# of Employees Covered under Plan
Anniversary Date