**Information received from this New Jersey Employee Health Insurance quote
request form sent to American Insurance Services Agency will be for our use only
and will not be sold, given to or distributed to any other parties. A quote will be based
on the employee health insurance plan information provided and does not guarantee
acceptance of the risk by us. The precise coverage afforded is subject to meeting
underwriting guidelines, and the terms, conditions and exclusions of the policy as
issued. By submitting this request you acknowledge that this is neither an offer to
insure nor a guarantee of insurance. Completion of this form does not entitle you
to a New Jersey Employee Health Insurance Plan Policy. We are licensed in New Jersey
and will not provide quotes for other states.
"Your New Jersey Group Health Insurance Plan Agent!"
We also offer affordable employee health insurance plans to businesses in the
following New Jersey counties and cities: Union County, Essex County, Bergen County,
Passaic County, Sussex County, Morris County, Warren County, Hunterdon County,
Somerset County, Middlesex County, Monmouth County, Mercer County, Burlington
County, Clark, Newark, Jersey City, Elizabeth, Rahway, Colonia, Iselin, Avenel,
Woodbridge, Port Reading, Carteret, Perth Amboy, Fords, South Amboy, Metuchen,
Plainfield, Dunellen, South Plainfield, Green Brook, Fanwood, North Plainfield,
Cranford, Scotch Plains, Westfield, Union, Millburn, Springfield, Mountainside, Gillette,
Warren, Watchung, Stirling, Millington, Middlesex, Martinsville, Piscataway, Edison,
New Brunswick, Highland Park, North Brunswick, Sayreville, East Brunswick,
Somerset, Milltown, South River, Bound Brook, Somerville, Bridgewater, Bayonne,
Linden, Roselle, Hoboken, Union City, Weehawken, West New York, Guttenberg,
Cliffside Park, Edgewater, North Bergen, Secaucus, Fairview, Ridgefield, Fort Lee,
Leonia, Palisades Park, Englewood Cliffs, Englewood, Bergenfield, Teaneck, Paramus,
Bogota, Ridgefield Park, Little Ferry, Hackensack, Maywood, Teterboro, South
Hackensack, Rochelle Park, Moonache, Lodi, Hasbrouck Heights, Saddle Brook,
Garfield, Elmwood Park, Woodridge, Carlstadt, East Rutherford, Lyndhurst, Rutherford,
Wallington, Passaic, Clifton, Paterson, Totowa, West Paterson, Little Falls, Great Notch,
North Caldwell, Cedar Grove, Verona, Montclair, Bloomfield, West Orange, Glen Ridge,
Belleville, Nutley, Kingsland, North Arlington, Kearney, Harrison, East Orange, East
Newark, Orange, Irvington, South Orange, Hillside, Townley, Livingston, Wayne,
Trenton, Camden, Atlantic City, Princeton, Vineland, Willingboro, and Toms River, NJ.
Business Name:    
Premises Address:
City:     State:     Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 
Description of Operations or SIC code:


Current Insurance Company: 
Policy Expiration Date:          (mm/dd/yyyy)



Do you currently offer health insurance benefits to employees?
Group Health Insurance Coverage For:
How many employees to be insured:    



HMO Group Health Insurance   HMO Co-Pay Amount Desired:  
PPO Group Health Insurance     PPO Deductible Amount Desired:
POS Group Health Insurance     POS Co-Pay Amount Desired:    
Fee-for-Service Insurance          Fee-for-Service Deductible:         


Choose Benefit Options:
Group Dental Insurance Coverage:
Group Vision Insurance Coverage:
Group Life Insurance Coverage:    

Has any employee to be insured experienced serious health
problems during the last 18 months?
If "Yes", please explain below.


Additional Information or Comments


Click on the "Submit Quote Information" button below to send your
New Jersey Employee Health insurance quote request.**


New Jersey Group Health Insurance Coverage Desired:
New Jersey Business Information:
Employee Information:
New Jersey Group
Health Insurance Quote
Request information about group health insurance for your New Jersey business.
Do you have questions about
employee health insurance?
We provide affordable Group Employee Health Insurance services to businesses in New Jersey!
Copyright 2004-2008 American Insurance Services Agency - All rights reserved
In addition to Employee
Health Insurance for your
New Jersey business, we
also offer affordable
Employee Life Insurance
plan premiums or choose
another NJ business
insurance coverage from
the list below.
Business Insurance
Quotes
Employee Health
Insurance Quote
American Insurance
Services Agency
1129 Raritan Road
Clark, New Jersey 07066
(732) 680-4444
Fax: (732) 680-4067
"We're Your New Jersey
Group Employee Benefit
Health Insurance Agent"