First Horizon Msaver Health Savings Accounts

EMPLOYER'S PARTICIPATION STATEMENT FOR GROUP QUOTE

EMPLOYEE CENSUS

First Horizon Insurance Services - Request for Group Health Plan Quote

Legal Company Name_____________________________

Address_____________________________

City, State & Zip Code_____________________________

How did you hear about First Horizon Msaver?_____________________________

Contact______________________

Phone #______________________

Fax #______________________

Email**______________________

Employee Name	Sex M/F	Emp. Age	Emp. Home Zip Code	Coverage (See Below)	Spouse Age	Number of Children	*Status (See Below)	Smoker (Y/N) (Emp./Sp.)	Current Premium
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*** List all employees even if they are not on the company insurance plan. You can indicate that they are covered under spouse.***

How much is your total health premium?

*STATUS CODES

FT = Full Time

PT = Part Time

CO = Cobra

COVERAGE CODES

S = Employee Only

ES = Employee + Spouse

EC = Employee + Child

F = Family

Please list the current health conditions in your
group (diabetes, heart, cancer, pregnancy, etc.)

_________________________
_________________________
_________________________

Current Driver?

Current Deductible?

Desired Deductible?

Coinsurance Amount? (In-Network|Out-of-Network i.e. 90%|80%)

Please Indicate the dollar amount (or%) of the insurance premium paid by the employer

How much is your total health premium?

Who will make the final decision on your health care plan?

What effective date would you like on this quote?

Please fax a completed form to 913-663-4675

If you have any questions, Please call 866-719-0735
If there are more than 10 employees please make a copy of this form to list all employees.
***LIST ALL FULL TIME EMPLOYEES, EVEN IF THEY ARE NOT ON THE COMPANY INSURANCE PLAN***
Primary Business(SIC)___________________________________________