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Group / Employer Insurance Quote Request

Choose one of the following options: Complete the online census form or download the form, fill it out and fax or scan/email it back in.

  1. Complete the census form below (If you have more than 15 employees you can put more than one in each employee box or submit the employee information in a separate email with a spreadsheet attached to trish@insurancelady.com)
  2. Download, Print and Complete a census form (Email to trish@insurancelady.com or fax to 225.622.3070)

Group / Employer Census

Please complete and submit the online form below for a group health quote. Once submitted we will contact you to discuss your quote as quickly as possible.

  • Enter Employee Information

    For more than 15 employees you may complete the form as many times as needed or email a spreadsheet to Trish@insurancelady.com with the following fields: Employee Name, Male/Female, Date of Birth, Spouse’s DOB, and # of Dependents

  • Enter Employee 2

  • Enter Employee 3

  • Enter Employee 4

  • Enter Employee 5

  • Enter Employee 6

  • Enter Employee 7

  • Enter Employee 8

  • Enter Employee 9

  • Enter Employee 10

  • Enter Employee 11

  • Enter Employee 12

  • Enter Employee 13

  • Enter Employee 14

  • Enter Employee 15