The Robbi Davis Agency : Group Quotes

The Robbi Davis Agency, Inc. is a full-service, independent insurance agency specializing in group benefits and managed care plans. The agency offers proposals and on-going service for all types of employee benefits, including group health, life, dental, disability, cancer, section 125 and long-term care plans.

Outstanding Service
Our team of experienced professionals strives to provide unprecedented service to all of our clients. We will assist you with ongoing employee education, claims issues and billing issues. We even provide an annual market evaluation of your in-force policies at no additional charge. Sixty days prior to your annual renewal date, we'll contact you for updated census data and health information. We'll provide a full market evaluation at least a month in advance of your renewal date. This will allow you to make a well-informed, educated decision.

Request a Group Quote
For businesses with less than ten employees, complete the form below in its entirety. For businesses with more than ten employees, fill out the form below with the exception of the Employee Information sections, and fax your census information directly to us at 501.954.8542. Please note in the "Additional Employee Information" text area (at the end of the form) that you are faxing your census information to us.

Company name: (required)

Exact nature of business: (required)

Number of years in business: (required)

Name of contact person: (required)

Address: (required)
Street:	City:
State:	ZIP:
County:

Contact person phone:	Email: (required)
Current carrier:	Proposed effective date:
Current rates (optional):
Which do you prefer? HMO or PPO
Do you want dental coverage? No or Dental included or Dental optional
Check if you want: Maternity coverage (optional for groups < 14 employees) Office visit copay
List any serious ongoing health conditions:

Employee information:
Employee 1:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Employee 2:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Employee 3:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Employee 4:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Employee 5:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Employee 6:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Employee 7:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Employee 8:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Employee 9:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Employee 10:
Initials (e.g., JFB):	Gender:
Date of Birth: (DD/MM/YY)	Check for tobacco use:
Number of dependents:
Coverage to include: Employee only Employee and spouse Employee, spouse and children Employee and children

Additional employee information:

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