Employee Benefits Quote Request

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* Required fields.

General Information
Your Full Name: *
Your Company:
Address:
City:
State:	Zip:
Business Phone: *	Fax:
E-mail Address: *

Type of Business
Type of Business:
Standard Industry Code: (if known)
No. of Full Time Employees:	Part-Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Health Insurance Information
Carrier (Company) Name: (not agency)
Please give a brief description of your current Group Health plan:

Benefits Desired
PPO Option: Yes No		HMO Option: Yes No

Major Medical Deductible:
Optional Pregnancy Coverage:		Yes No
Supplemental Accident Coverage:		Yes No
PCS Card (Prescription Disc. Option):		Yes No
Dental Coverage:		Yes No
Disability Insurance:		Yes No
Group Life Insurance:	Yes No	Amount: $

Employee Information
Please list all employees you wish to cover:
Employee Name	Date of Birth	Age	Sex	Dependent Status
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or e-mail an additional listing.

Additional Comments or Questions

Please click the "Submit Quote" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.


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