Employee Benefits Quote Form

Company Information Section

Important: Fill in the Information below as requested. Salary is only required for Disability quotes.
Make sure click on the "Submit" button at the bottom of this page.

Company Name   Phone -    Fax -   E-mail
Street    City    State    Zip-Code
Nature of Business    SIC Code, (if known)
Number of Full-time employees working 30 hours or more    Effective Date of Coverage

Benefit Information

Please send me a quote on (check each that applies):

Group Medical Group Dental Group Disability Group Life Amount of Life Insurance Group Vision

Group Medical: Office Co pay Inpatient Hospital Co pay/Deductible

High Deductible Health Plans for use with an HSA

High Deductible Plan Coinsurance after deductible is satisfied

Employee Information (Click "SUBMIT" button below when complete)

First Name Last Name Date of Birth Sex Employee Status Weekly Salary (Disability only)

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Contact us if you employee more than 25 eligible employees.
Our office will make arrangements to receive your employee census in a manner most convenient to you.

Contact Person

Send quote in the form of    Facsimile Mail E-mail Phone

Make sure you click the SUBMIT button >>>

Call us @1-800-289-8376 with any questions.

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