INFORMATION REQUEST FORM
Business Name
Contact Person
Phone # / ext.
E-Mail
Address
Address 2
City
State
Zip Code
Number of Employees
Full time
Part time
1099 Contract
Do you currently provide major medical insurance to your employees?
Yes
No
If yes, please identify a provider below
If yes, what percentage of your employees are participating?
%
For those who are not insured under your current major medical program, please help us understand why (check all that apply)
Not eligible
Too expensive
Has other coverage
Contract worke
Would you like more information on offering our limited medical program to your employees?
Yes
No
Would you like more information on benefits such as:
Major Medical
Limited Medical
Universal Life / Whole Life
Term Life
Critical Illness
Dental
Disability Income
Legal
Vision
Other
Benefit Communications
AVAILABLE FORMS
Please select the forms that you would like:
Master Application
Employee Application
New Business Transmittal
Claim Form
Change Form
Termination Form
COMMENTS / QUESTIONS
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