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P I A M
860 Winter Street
Waltham, MA 02451-1414
toll free 800-522-7426
tel 781-434-7525
fax 781-434-6929
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 Health Insurance Quote Request
Fill out and submit form below or click on download census, print the pdf file, fill it out and fax it to 781-434-6929. Note that we can only write group health and dental in Massachusetts.
General Information
Practice Name:
Address:
City:
State:
Zip:
Contact Name:
Business Phone:
E-Mail:
Fax:
Total Number of Active Employees:
How many of these are not eligible due to part time status or have spousal coverage?
What type of insurance are you interested in?
Employee Information
 Please list every active employee, including yourself
Employee #1
Date of Birth:
Coverage Needed:
Number of Children:
Check if Part-Time (not eligible): Yes No
Covered through spouse's employer? Yes No
Employee #2
Date of Birth:
Coverage Needed:
Number of Children:
Check if Part-Time (not eligible): Yes No
Covered through spouse's employer? Yes No
Employee #3
Date of Birth:
Coverage Needed:
Number of Children:
Check if Part-Time (not eligible): Yes No
Covered through spouse's employer? Yes No
Employee #4
Date of Birth:
Coverage Needed:
Number of Children:
Check if Part-Time (not eligible): Yes No
Covered through spouse's employer? Yes No
Current Coverage
  
Present Insurance Company:
What do you currently pay each month: Ind: Fam:
Submit:
Disclaimer: Our online application forms are to provide current and prospective clients an indication of premium only. No coverage can be bound by this process. Hard copy, original signature, long form applications must first be obtained. Only after an insurance company has underwritten and provided written terms from this office can coverage be ordered.

Download Census

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