Request a Group Quote

Please fill out this short questionnaire as much as possible so that we can better analyze your needs.  Note: not all fields are necessary, but more information will help us serve you better. Or, you can print out this PDF and fax or mail it in.

Broker Info

Broker:

Agency:

Agency Mailing Address:

Phone:

Fax:

E-mail:

Client Info

Name:

Type of Business or SIC:

City:

State:     Zip Code:

Effective Date:

Needed By:

Current Plan Design

(for Vision, Life, Disability quotes, skip this section)      Current Carrier

Insured    Self-Insured

Preventative &Diagnostic Basic Major Ortho In-Network % % % % Out-of-Network % % % % Deductible: $ Does it apply to preventative / diagnostic? Yes    No Annual Benefits: $ per person / per year Orthodontic: $ Lifetime Max.

Current Rates

Single:

Employee + 1:

Employee + Children:

Family:

Renewal Rates

Single:

Employee + 1:

Employee + Children:

Family:

Contribution

Single Rate: $

Employee Contribution: $

Employer Contribution: $

Dependent Rate: $

Employee Contribution: $

Employer Contribution: $

Current Participation

Total Number of Employees:

Number of Employees in Plan:

Please include Census Data with M/F, DOB and Family Status

Please submit the form only once. It may take a moment to process.