Contact Your Community Healthcare Cooperative Representative

Affordable Healthcare Quote Request

Reach Out to Us for an Affordable Healthcare Plan for your company.

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Company Name

Contact Name

Street Address

City

State/Country

Zip Code

Phone Number

Preferred contact method

Total number of employees/staff

Do you currently offer healthcare insurance to your staff?

If so, how many staff are on the healthcare plan?

What is the total monthly cost for the staff that are on the plan?

Do you subsize any of your staff’s cost?

If so, what is your monthly subsidy cost?

Number contact Number

Please enter number of employees/staff for each age category.

Number of staff under 21

Number of staff ages 21-30

Number of staff ages 31-35

Number of staff ages 36-40

Number of staff ages 41-45

Number of staff ages 46-50

Number of staff ages 51-55

Number of staff ages 56-60

Number of staff ages 61-65

Number of staff over age 65

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