Ohio CPA Benefits: Group Quote

Small Businesses (50 or fewer employees)

It's easy to receive a quote for your group medical coverage. Just complete the information below and then click on the Submit button at the bottom of the page.

It's that simple! Or, download the Excel version of the Census File and email your information to us at the address below.

The Employer and Employee paper enrollment forms are also available by clicking on these links.

Electronic online employee enrollment is now available. Ask us about this simple and convenient alternative to paper applications.

Questions? Call the closest office and ask for Small Business Group Benefits or email us at OSCPABenefits@OswaldCompanies.com.

Items in red are required.
Name of Company:
Street Address:
City:
State:	Zip:
SIC Code or Industry:
Fed Tax ID #:
Contact Name:
Contact Phone:
Contact Email:
Current Insurance Carrier:
Renewal Date:
Monthly Premium:
Deductible:
Special Notes:

PLEASE LIST ALL EMPLOYEES WHO ARE ELIGIBLE
(FULL-TIME EMPLOYEES WHO WORK 25 HOURS OR MORE PER WEEK)

	Employee (Use name or ID number, or even Employee 1, Employee 2, etc.)	Employee DOB	Sex	Medical Coverage [EE Only, EE & SP, EE & Child(ren) or Family]	Spouse DOB	# of Dependents	Employee Status for Medical [Active, COBRA, Retired, Waiver]	HOME ZIP Code
	Joe Example	01/19/70	F	Family	02/09/70	3	Active	44114
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