Get a Quote for Insurance

Affincon is here to help your with all your group health insurance needs. Please complete the form below and an agent will contact you shortly to consult with your about the group health plan for your company.

Group Health Insurance Quote Form

Fields marked by an asterisk (*) are required fields.
 

Company Information


Company Name:*      Tax ID: 
Type of Business:*
SIC #:   
Years in Business:*  
Number of Employees:*  
 

Contact Information


Contact Name*
Address   Unit/Apt/Lot #  
City   State     Zip  
County
Email*
Contact Phone   Fax 
Best Time to Call
 

Requested Coverage Information


Health Coverage Requested:      
Effective Date Requested
 

Current Coverage Information


Current Coverage: 
Current Carrier: 
 

Employee Information


Name DOB Sex Smoker Zip Code Coverage Requested

The protection of your privacy is important to us. Rest assured that the personal information you provide us with will not be disclosed to other parties and will be used solely for the purpose of bringing you the best service possible.
Life insurance

""I can recommend Ron Dutton, without reservation, as an expert in helping to find the best and most affordable insurance coverage available. Mr. Dutton helped me untangle the enormous mountain of information I received as I became eligible for Medicare. He listened carefully to my needs and concerns and used his exceptional expertise to advise me concerning my new coverage needs. Mr. Dutton is not only an expert in his field he is a man who can be trusted.""
Janet Love
Lawrenceville, GA