INFORMATION REQUEST FORM FOR BROKERS
Agent Name
Agency Name
Phone # / ext.
E-Mail
Address
Address 2
City
State
Zip Code
BROKER INFO
Are you in the group benefits, worksite benefits, P&C business or all of the above?
Would you like more information on offering our limited medical program to your employees?
Yes
No
If yes, with which carriers?
What is the average size of your current or prospective accounts?
What, if any, additional products and services are you interested in?
(check all that apply)
PRODUCTS
Term and Permanent Life Insurance
Critical Illness
Disability
Indemnity Dental
SERVICES
Communication & Enrollment
Consolidated Billing
Self funded Plan administration
Section 125 Plan (Cafeteria) administration
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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