Application Request Form

To receive an accurate quote, all information should be included.
Please supply an e-mail, fax, mailing address or call
(800) 392-6958.
 **Please note, the submit button is at the end of the form.

Client Data:

Company Name:
Address:
City, State, Zip:
E-mail:
Business Phone:
Nature of Business:
Current Carrier(s):
SIC Code:    Effective Date for plan(s):
Current Plan(s) Design:
Current Rates:
Single $   H/W $   P/C $   Family $

Census Data:

Name

Date of Birth

Sex

Dep. Status

Zip Code

PCP
(if available)

Life

LTD
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Proposal Specifications:

Carrier(s)

Products Riders, etc.
 Aetna/USHC  HMO
 Amerihealth  POS
 BlueCross BlueShield  PPO
 CIGNA  Open Access
 First Option Health Plan  Office Co-pay  
 Health Plan of America  Co-insurance 
 Oxford Health Plans  Deductible 
 PHS/Guardian  Waive Hospital Co-pay
 Prudential  Rx
 United Health Care  MSA
 University Health Plan  Dental
 US Life  Vision Rider
 Other (Please Specify Below)  Extended Student Rider
   Group Disability
   Group Life
   401K
   Payroll services quote
   COBRA administration
   Section 125 setup
   Other

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York-Jersey Underwriters  ~  P.O. Box 810  ~  Red Bank, NJ  07701
Conveniently located one mile east of the Garden State Parkway at exit 109
In eastern Monmouth County N.J. 
(732) 842-2012  ~  (800) 392-6958  ~  fax:  (732) 530-7080
E-mail: sales@york-jersey.com

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