Group Benefits Proposal Request

In order to obtain a quote please fill out the following form and click "SUBMIT" below. We will automatically receive your information and begin working on your quote immediately. If you would like to discuss the quote request with us, please contact our office.

If you are requesting a Medical, Dental or Vision quote, you do not have to complete the 'Occupation' and/or 'Annual Earnings' sections. However please be sure to complete the 'Type of Coverage' section.

If you are requesting a 'Short or Long Term Disability' quote, or a 'Life Insurance' quote based on annual earnings, please complete the 'Occupation' and 'Annual Earnings' sections. However, you will not need to complete the 'Type of Coverage' section for these lines of coverage.

If additional information is needed in order to process your quote request, we will contact you.

All fields are required unless indicated optional.

If more than 5 , how many employees do you want to list?

This quote is for:

Medical Dental Vision Short Term Disability Long Term Disability

Company Name:

Contact Name:

Company Address:

City:

State:

Zip:

Email Address:

Your Phone Number:

Extension:

(optional)

Fax Number:

What is the nature of your business?:

What is your company's Standard Industrial Classification (SIC)?

(optional)

When was this company started?

(mm / dd / yyyy)
/ /

Do you currently have a Plan?

Yes No

If so, please indicate the line of coverage and the carrier. Please also give a brief description of each plan:

#	Employee Initials	Gender	Employee Zip Code (if out of area)	Employee Date of Birth (mm/dd/yyyy)	Occupation/Title	Annual Earnings (Excluding Overtime & Bonuses)	Type of Coverage
#	Employee Initials	Gender	Employee Zip Code (if out of area)	Employee Date of Birth (mm/dd/yyyy)	Occupation/Title	Annual Earnings (Excluding Overtime & Bonuses)	Medical	Dental
1.
2.
3.
4.
5.

Close This Window

Copyright � <% =Year(Date()) %> Your Agency Name