Your Name (required)


    Your Email (required)

    Full Legal Name of Business

    Street Address

    Street Address Cont.




    Work Number

    Email Address

    Best Time to Contact

    Group Profile

    Current Census Data including: dob/age, male/female and single/family.

    Age bracketed census (if available)

    Type of business

    Number of locations

    Number of employees

    Number of subsidiaries

    SIC Code

    Effective Date

    Benefit Description

    Schedule of current plan benefits

    Any recent or future plan revisions


    Minimum two years of premium and claims experience

    Month by month with employee counts by month

    Renewal rates

    Details of any shock claims or large pending claims

    Any employee or dependent disabled or not actively at work

    Is plan contributory? If so, what percentage?

    Group life insurance information, if required

    Are retiree lives covered, if so, provide details.

    Is Group currently fully insured?

    Is the Group partially self-insured? If yes, how many years?

    Contract Type

    Contract Type


    Benefits to be covered under aggregate

    Aggregate accomodation

    Life time max


    Date quote is needed

    If you have any questions as to why we are requesting any specific item listed above, please call us at 800-680-0892. If you are mailing the information to us, use the address listed below.