Employee Benefits Quote Request

Please fill out completely. Thank you.

CONTACT INFORMATION

Name of Business:

Address:

City:

State: Zip:

Phone:

Fax:

Contact Person:

Title:

Ext:

Email:

COMPANY INFORMATION

Nature of Business:

Years in Business:

Current Provider:

Renewal Date:

Reason for Change:

Employer Contributions:

Employee % Dependents %

Number of COBRA Participants:

Knowledge of Pre-Existing Conditions:

Knowledge of any Disabilities?:

CURRENT BENEFITS

Please check all benefits currently being provided, and identify co-payments or other relevant information in the spaces provided.

CURRENT RATES

Employee:

Employee & Spouse:

Employee & Family:

OTHER INFORMATION

Potential Effective Date:

Sec. 125 Plan Administration:

Does your company currently provide a Section 125 Plan?
Yes No

COBRA Administration:

Who completes the COBRA Administration for your company?
Inhouse Administration Outsource Administration