American Health Administrators

Group Activities Insurance Quotation Request Form

Please give us the following details, so we can return a quote.


Name of Organization ________________________________________________________

Nature of Organization ______________________________________________________

Street Address ________________________________________________________________________

City___________________________________State/Zip______________

Phone (    )____________________________________________________

Please give us your name as the contact person and your e-mail address or phone number, whichever you prefer that we use to contact you.

___________________________________________    __________________________________


Number of participants _____________________

Effective date desired _____________________

Termination date desired _____________________

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