Mid-America Specialty Markets
2718 Forum Blvd., Ste 3B
Columbia, MO 65203
573-447-4990
info@midaminsurance.com
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Group Health Insurance Quote

Complete this form to get your Missouri group health insurance quote

To receive an insurance quote simply complete the Insurance Quote Request form below with as much information you can and click submit. Once we receive your request we'll have an agent contact you as soon as possible.

Mid-America Specialty Markets provides group health insurance quotes and coverage to businesses in Missouri, Mid-Missouri and Central Missouri including the communities of Columbia, Jefferson City and Lake of the Ozarks.

Please note this form is used only to request a quote. No coverage is provided by completing this form. Your privacy is important to us. We will not ask for personal private information on our quote request forms. We will not distribute, sell or otherwise use for any other purpose than to answer your request your name, physical address, phone or email address.


GROUP HEALTH INSURANCE QUOTE REQUEST

Business Name
Contact Name
Address
City/State/Zip
Phone / Fax
Email
Type of Business
Yrs in Bus
Describe your business
Current Ins Company
# of full time employees
# of part time emp
Describe you current coverage, deductibles, copays, meds
Complete the below census
Emp #
Sex M-F
Age
Smoke Y-N
Coverage Type
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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18
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20
Questions or comments


IMPORTANT NOTICE

Completing and submitting this form DOES NOT bind or provide you with insurance coverage. This form is used only to request a quote. No coverage is provided by completing this form. Please contact our office with any questions.



Contact us for all of your insurance needs:

MID-AMERICA SPECIALTY MARKETS
2718 Forum Blvd., Suite 3B, Columbia, MO 65203
Voice: (573) 447-4990
Fax: (573) 447-4998
email: info@midaminsurance.com

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