Select Your Agent DayInsSolutions Scott DayDave McKeeRob WeaverRuss ConroySara StevensTeresa DayYolanda FrasierLyla AccardiSara Gilpin Business Name:  * Contact Name:  * Email Address: Address:  * City:  * State:  * Zip Code:  * Phone Number  * Renewal Date JanuaryFebruaryMarchAprilMay JuneJulyAugustSeptemberOctoberNovemberDecember Group Size 2 - 1011 - 5051 - 99100 - 9991000 or more Plan Type PPOHMOHSAHRAOther Deductible $0$250$500$1000$1500$2000$2500$3000 Co-Insurance 100/090/1080/2070/3060/4050/50 Dr. Co-pay $0$10$20$30$40 Specialist Co-pay $0$10$20$30$40 RX $10/20/40$10/30/50$10/35/60Other-See CommentsNone Employee #1 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Employee #2 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Employee #3 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Employee #4 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Employee #5 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Employee #6 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Employee #7 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Employee #8 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Employee #9 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Employee #10 - Age Male Female Employee Employee/Spouse Employee/Child Family Waive coverage Known Medical Conditions Aids/HIV Cancer COPD Diabetes Depression/Anxiety Epilepsy/Seizures Fatigue disorders Heart Disease Multiple Sclerosis Muscular Dystrophy Rheumatoid Arthritis Stroke Other/Use Comment Box Comments: Do not enter anything in this field:

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