Purchasing Alliance Solutions, Inc. Group Quote Request


Group Information

Group Name
Group Contact Name
Group Contact Phone
Group Contact Email
Agent Name
Agent Phone
Agent Email
Type of Business
SIC Code	Links to SIC Lookup
Requested Effective Date
Zip
County	Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Crisp Dade Dawson Decatur DeKalb Dodge Dooly Dougherty Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe Montgomery Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth Not in GA
State
Number of Total Employees
Number of Eligible Employees
In business for 2 or more years?	Yes No
Multiple Locations?	No Yes
Apply Chamber Discount?	Yes No
Current Carrier (if not listed, enter below)	Aetna / US Healthcare AmeriHealth Blue Choice Blue Cross Blue Shield Cigna Doctors Health Plan Fidelity Geisinger Health Plan Great West Guardian Health Plan of UOV HealthAlliance Medical Plans Humana John Alden John Deere MAMSI Medical Mutual Mercy Mid Atlantic Mutual N/A North American Ochsner Health Plan Optimum Choice Partners Preferred Health Network Preferred Health Sytems Principal Terminated Prior to Cvty Acquisition TPA Ultramed Choice Unicare Union Insurance United Healthcare Unknown, due to CHC Term Unknown, due to Going out of business Unknown, due to Merger UPMC
If current carrier is not listed above, please enter it: