GHS — Client Information Form

Quick & easy — this single form is all we need. Takes about 5 minutes. We handle everything else. Your GHS advisor will use this to pull quotes from top carriers and build your customized benefits proposal at no cost to you.

Section 1 — Company Information

Legal Company / Group Name *

EIN (Federal Tax ID) *

Street Address *

City, State *

Zip Code *

Industry / SIC Code

Primary Contact Name *

Contact Email *

Contact Phone

Desired Effective / Go-Live Date *

Current Renewal Date (if applicable)

Section 2 — Employee & Eligibility Counts

Total Full-Time Employees *30+ hrs/week, W2 only

Part-Time Employees

# Eligible for Benefits *

# Expected to Enroll

Avg Annual Salary (approx)Used for PrimeCare savings calc

State of Company (Situs)

W-4 Version Used

2019 or before 2020 or later

Multiple Locations?

Yes No

Section 3 — Current Coverage & Carrier History

Current Health Insurance Carrier

Current Funding Type

Fully Insured Level Funded Self-Funded None

Previous Carrier (if any)

Years with Current Carrier

Section 4 — Benefits & Carriers to Quote Check all that apply

Complete one row per full-time employee · Only fill pages you need for your group size

#	First Name *	Last Name *	M/F	Date of Birth *	Home Zip *	Work Zip	Annual Salary *	Job Title	Coverage Tier	Filing Status	# Dep.

Coverage Tier: EE = Employee Only · ES = Employee + Spouse · EC = Employee + Child(ren) · EF = Employee + Family · W = Waive · D = Decline | Filing Status: Single · Married Filing Jointly (MFJ) · Married Filing Separately · Head of Household

Complete one row per full-time employee · Only fill pages you need for your group size

#	First Name *	Last Name *	M/F	Date of Birth *	Home Zip *	Work Zip	Annual Salary *	Job Title	Coverage Tier	Filing Status	# Dep.

Coverage Tier: EE = Employee Only · ES = Employee + Spouse · EC = Employee + Child(ren) · EF = Employee + Family · W = Waive · D = Decline | Filing Status: Single · Married Filing Jointly (MFJ) · Married Filing Separately · Head of Household

Complete one row per full-time employee · Only fill pages you need for your group size

#	First Name *	Last Name *	M/F	Date of Birth *	Home Zip *	Work Zip	Annual Salary *	Job Title	Coverage Tier	Filing Status	# Dep.

Coverage Tier: EE = Employee Only · ES = Employee + Spouse · EC = Employee + Child(ren) · EF = Employee + Family · W = Waive · D = Decline | Filing Status: Single · Married Filing Jointly (MFJ) · Married Filing Separately · Head of Household

Complete one row per full-time employee · Only fill pages you need for your group size

#	First Name *	Last Name *	M/F	Date of Birth *	Home Zip *	Work Zip	Annual Salary *	Job Title	Coverage Tier	Filing Status	# Dep.

Coverage Tier: EE = Employee Only · ES = Employee + Spouse · EC = Employee + Child(ren) · EF = Employee + Family · W = Waive · D = Decline | Filing Status: Single · Married Filing Jointly (MFJ) · Married Filing Separately · Head of Household