Please fill out this short questionnaire as much as possible so that we can better analyze your needs.
Or, you can download, print out
this PDF
, and email or fax it in.
Note:
If you are interested in quickly checking prices
, Please use our
Quote Calculator.
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
Upload A File
Select a file to upload:
Please submit the form only once. It may take a moment to process.