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Whether you are looking for major medical (PPO, HMO, HSA), mini-med, dental/vision, or disability insurance for your company, LKJ Financial will:

  • Help you find an insurance plan that fits your employees’ needs and your budget
  • Guide you and your employees step-by-step through selecting a plan and enrollment
  • Service your group's account to assist with claims or administrative issues
  • Shop your group at renewal to ensure you receive the most competitive rates and plans available

Group Medical Request

(* denotes required field)


What are you interested in?*

Interested in group medicalInterested in group dentalInterested in group visionInterested in group lifeInterested in group disability

Interested in group disability? List each employee's job title/salary:




Contact info:


Company Name:


Contact Person*:

Email*:

Street:

City:

State:

Zip*:

Phone:

Fax Number:

Current Insurance Carrier:




Employee Census
If you have more than 20 employees, send this page, then reset this form and re-enter additional employee information. At least one employee's information must be filled out.

Employee Last Name*: Date of Birth*:Dependent Coverage?* Spouse DOB:Home Zip*:
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Desired Effective Date:

Please place additional Comments/Requests in box below:

Prefer the phone? Call us at 713.840.0534