At ABI Agency we offer you a free, convenient and friendly quote that you can take online.

  • Are your health insurance costs too high?
  • Would you like more options and better service?

We at ABI specialize in providing
GROUP HEALTH INSURANCE to the
Small Business Marketplace.

To receive a proposal without cost or obligation, please take a few minutes to complete this form and return it to us.

ABI AGENCY QUOTE
ABI AGENCY QUOTE FORM

Business Name:

Contact Name:

Address:

City: , State: Pennsylvania
Zip:
Work Phone
Fax
E-mail

Description of Business

Number of Full Time Employees

Employee Census:
Employee #1 Name:
Employee #1 Date of Birth:
Employee #1 Status:
Employee #1 Home Zip Code:

2nd Employee

Employee #2 Name:
Employee #2 Date of Birth:
Employee #2 Status:
Employee #2 Home Zip Code:

3rd Employee:
Employee #3 Name:
Employee #3 Date of Birth:
Employee #3 Status:
Employee #3 Home Zip Code:

4th Employee:

Employee #4 Name:
Employee #4 Date of Birth:
Employee #4 Status:
Employee #4 Home Zip Code:

5th Employee:

Employee #5 Name:
Employee #5 Date of Birth:
Employee #5 Status:
Employee #5 Home Zip Code:

If you have additional employees please contact us at
ABI Agency
Phone 1.724.864.3677
Fax 1.724.864.3242

Comments or Special Requests:




Please select "Submit" to send this form via E-mail
or you can Print and
Fax it to ABI Agency at: 724.864.3242

ABI Agency
P O Box 100
Irwin, PA 15642
Phone 1.724.864.3677
Fax 1.724.864.3242

Questions?
Email us at info@abiagency.com