Davis Insurance Group
Employee Benefits
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Company Information:
Company Name:
Address:
City:
Zip Code:
State:
Phone Number:
Fax Number:
Contact Name:
Nature of your business:
Requested Effective Date:
Employee Information:
Please list below all of the full time employees who wish to participate in the plan.
Employee
Birthday
or age
 Spouse
Birthday
or age
 Number
of
Children
 If requesting a Disability
quote, we will need the
employees annual salary
Employee Name
 M/F
 Zip Code
Please tell what type of quotes you are looking for:
Health Insurance:
 Life Insurance:
 Dental Insurance:
Disability Insurance:
 Retirement Plans:
 Payroll Deduction Plans:
What is the requested effective date of the plan:
Requested Health insurance deductible:
Note: To select more then on option, hold
down the control key while making your
selections.
Health Insurance co-insurance:
Please check all of the following you would like to include on your plan:
Doctor co-payments:
 Drug Cards:
 Maternity Coverage:
Note: Maternity coverage is automatically included
on groups of 15 or more in North Carolina.
Health Savings Account (HSA) plan:
For your free quote, please complete the following information and one of our insurance professionals will contact you shortly.
We represent most of the major
North Carolina group health
insurance carriers. Whether
you have a business with one
employee or a business with
500 employees, we can help.
We have the traditional North
Carolina group health
insurance plans with
co-payments and deductibles,
Health Savings Account plans,
Health reimbursement plans,
Flexible spending accounts and
Cafeteria (Section 125) plans.
We also offer North Carolina
group Life Insurance plans,
North Carolina group dental
plans, North Carolina group
disability plans, North Carolina
group long term care plans,
North Carolina retirement plans
and North Carolina payroll
deduction plans.
To receive your North Carolina
group health insurance quote,
please complete the attached
form and press the submit
button. If you have more then
15 employees, please click
here, and we will e-mail you a
census form for you to
complete.  
Once we receive your request,
we will have at least four quotes
within two days for you to view.
If you have any questions,
please feel free to give us a
call. We look forward to working
with you in the future.
North Carolina
Short-Term
Medical Insurance
Do you have an employee
that will be leaving soon? If
so, that employee may want
to consider a North
Carolina short term medical
insurance plan to provide
them coverage in between
jobs. These plans can be
kept up to 12 months and
have attractive premiums
Apply online today.
Call Us Today For your Free
Insurance Quote
(910) 392-5173 or (877) 753-2847
A North Carolina Insurance Agency
North Carolina / South Carolina
Group Health Insurance Quote Request