Employee Benefits Insurance Quote

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

General Information
Legal Name of Business:
Contact Name: *
Address:
City:
State:	Zip:
Business Phone: *	Fax:
Best Time To Call:	AM   PM
Contact Email Address: *

Type of Business
Type of Business:
Standard Industry Code (if known):
# of Full Time Employees:	# of 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
Major Medical Deductible:	Please Select $200 $250 $300 $500 $1,000			Optional Pregnancy Coverage:	yes   no
Dental Coverage:	yes   no			Supplemental Accident Coverage:	yes   no
Disability Insurance:	yes   no			PCS Card: (Prescription Discount Option)	yes   no
Group Life Insurance:   Amount:	yes   no $			PPO Option:	yes   no
				HMO Option:	yes   no

Employee Information
Please list all employees you wish to cover:
Employee Name	Date of Birth	Age	Sex	Dependent Status
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Please Select Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
If you were unable 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 email an additional listing.

Additional Comments

Please make any additional comments you feel appropriate for this quote.

	Enter Security Code:

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.