2025-2026 Contractor Quote Program - Health Insurance Coverage.

The goal is to allow you and your broker a chance to offer you another type of insurance coverage that could help you reduce your overall costs for health care insurance and costs for you and your employees. This plan does not require you to change your current broker. This is a direct access offer through Indiana PHCC.

Company Legal Name(Required)

Requested Effective Date (Start of coverage date)(Required)

Federal Tax ID

Nature of Business(Required)

SIC Code

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Fax

Contact Name(Required)

Title(Required)

Contact Email(Required)

Full Time Employees(Required)

Part Time Employees(Required)

COBRA(Required)

How many have been on disability or FMLA over the last 12 months?(Required)

Today's Date(Required)

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2025-2026 Contractor Quote Program - Health Insurance Coverage.

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