Weis Insurance Agency Home Page Auto Insurance Home Insurance Business Insurance Life & Health Insurance Claims Customer Service Health Products Commercial Products Personal Products
Secured by SSL

Group Medical Insurance Quote Form


If you currently have a Group Medical plan in place we will need a copy of your most recent billing from your current insurance provider and a copy of your current benefit highlight sheet.  You can scan and email a copy of your most recent billing and benefit highlight sheet to Kate Passalacqua at katep@weisinsurance.com or simply fax a copy to (217) 342-9876. 

Personal Information
First Name
Required
Last Name
Required
Company Information
Company Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Do you currently have insurance?
Optional
Current Insurance Provider
Optional
Current Policy End Date
Optional
/ /
Nature of Business
Optional
Are there any Major Medical Conditions?
Required
Describe any major medical conditions that exist.
Optional
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Auto Insurance Quotes and Home Insurance Quotes Powered by AgentInsureAuto Insurance Quotes and Home Insurance Quotes Powered by AgentInsure
Like Us on FacebookFollow Us on Twitter