Health & Life of Kansas City <> MOKAN Health <> Group Coverage

Group Coverage Questionnaire Sheet

Thank you for considering Health & Life of Kansas City for your insurance needs. Please complete the following information so we may obtain the most accurate quotes for your company. You will also want to submit a copy of your most current schedule of benefits, an updated census, and any special request you may have to our office so we can solicit competitive quotes for your review. Feel free to contact us is you have any questions.

General Information

SECURE

Company Name:
Contact Person:
Email Address:
Office Address:
Phone Number:
Fax Number:
Nature of Business:
SIC Code:
Number of Employees/Dependents:
Current Insurance Vendors: Effective Dates:
Summary of Requested:	Medical Dental Life AD&D Disability
Contribution %	Employee: Employer:
Effective Date:
Bid Deadline:
Current Premium:
History of Rate Increases:

How did you hear about Health & Life of Kansas City?

When clicking Submit, you will be taken to the census information form.

Health & Life of Kansas City
425 Washington Street, Suite 302
Kansas City, MO 64105
Phone: (816) 471-7747 Fax: (816) 471-7764
health@mokanhealth.com