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Group Benefit Quote Request


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Quote Type
Optional


Broker Name
Required
Date/Time Needed
Required
Effective Date/Renewal Date
Optional
Contact Information
Company Name
Required
ZIP / Postal Code
Required
First Name
Required
Last Name
Required
Primary Phone Number
Required
E-Mail Address
Required
Coverage Information
Types of Coverage
Optional



Prior Coverage
Required
Current Carrier
Required
Current Plan(s)
Required
# of FT Employees
Required
# of PT Employees
Required
Total FTE Count
Required
Is This Company Part of a Controlled Group?
Required
Employer Contribution
EE
Required
DEP
Required
# of Years in Business
Optional
Plans to be Quoted
Optional



RBG Carriers to Be Quoted
Optional


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Upload Census Spreadsheet
Optional
Additional Comments
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.