Request A Quote Quote Form Step 1 of 10 10% Name* First Last Email*Where should we send your quote? Phone*In case we have addiional questions what is the best number to call you?Is this a cell phone? Yes No Date Of Birth* Month Day Year Address* State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you use tobacco products* Yes No Date Last Used* MM slash DD slash YYYY Physical Gender* Male Female Is this coverage for your Business, Self or Family?*Select All That Apply Business Self Applicant and Child(ren) Child Only Family Self and Parent(s) Self and Spouse What type of Business Coverage are you looking for?*Select All That Apply Employee Benefits (Medical, Dental, Vision, Life) Coverage for Owners, Partners & Key Personnel Retirement/Succession Planning (Pensions) Something Else How did you hear about us? General Business InformationBusiness Name* Your Business Title* Industry Tax StatusC CorpS CorpSole ProprietorPartnership (Including LLP)LLC Taxed as C CorpLLC Taxed as S CorpLLC Taxed as Sole ProprietorTax Year EndDecember 31November 30October 31September 30August 31July 31June 30May 31April 30March 31February 28January 31NANumber of locations* Number of employees to be insured*Includes part-time and full-employees Number of FTE equivalents*This is calculated by the total number of hours paid divided by 40. Company Website Corporate Headquarters Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Employee Benefits InformationDo you already have employee benefits in force? Yes No If Yes, please upload current benefits summaryMax. file size: 256 MB.Next, upload your Group CensusMax. file size: 256 MB.Or Download our Group Census Template and Upload itMax. file size: 256 MB.What types of benefits do you want quotes for?* Select All Medical Dental Vision Life Supplemental Only (Critical Illness, Accident, Disability, Hospitalization) Owners, Partners & Key Personnel InformationDo you have benefits for owners, partners and or key personnel already in force?* Yes No If Yes, please upload current policy summaries of all insured for comparative and competitive quotes.Max. file size: 256 MB.Next, upload your Group CensusMax. file size: 256 MB.Or Download our Group Census Template and Upload itLINKMax. file size: 256 MB.What types of benefits do you want quotes for? Select All Medical Dental Vision Life Supplemental Only (Critical Illness, Accident, Disability, Hospitalization) Retirement/Succession Planning InformationIs there is a current pension plan in force you would like to have reviewed?* Yes No If Yes, what type of Retirement/Succession Plan do you have and how long has it been in force? Approximate contribution desired Do the owners/partners have ownership interests in other firms? Yes No Will this review or proposal contain more than 100 employees? Yes No What types of benefits do you want quotes for? Key Employee Life Insurance 401ks and Pensions Deferred Compensation 162 Executive Bonus Plans Buy/Sell Agreements Disability Insurance Medical Dental Vision Other Life Insurance options. Please provide additional comments related to plan design, such as type of plan desired, which employees to favor etc. Something ElsePlease provide additional comments related to your insurance needs. Coverage For SelfWhat Has You Looking For Coverage for Yourself? Between Jobs COBRA Coverage Ending Dissatisfied with current plan Entering/In My Initial Enrollment Period (IEP) for Medicare Switch from Medicare Advantage back to Original Medicare Family Structure Change Haven't had Health Insurance in a long time Life Event Losing Employer Health Coverage Need Prescription Drug Benefits Price Provider Availability Relocation Others Please Specify What do you dislike about your current plan most? (Check all that apply) Cost Lack of network providers Benefits included I don’t have insurance Other Please Specify If you have a copy of your current benefits please upload the file here: Drop files here or Select files Max. file size: 256 MB. Who is your current insurance carrier? Which Types Are You Interested In for Yourself?* Medical Dental Vision Life Supplemental Only (Critical Illness, Accident, Hospitalization) Disability Long Term Care Final Expense Medicare What specific Medicare? Insurance What specific Life Insurance Life Insurance for Mortgage Protection Life Insurance for Asset Protection Index Universal Life Insurance Life Insurance for Legacy Protection Life Insurance for Other Please Specify Coverage For DependentsWhat Has You Looking For Coverage for Your Dependents? Between Jobs COBRA Coverage Ending Dissatisfied with current plan Entering/In Their Initial Enrollment Period (IEP) for Medicare Switch from Medicare Advantage back to Original Medicare Family Structure Change Haven't had Health Insurance in a long time Life Event Losing Employer Health Coverage Need Prescription Drug Benefits Price Provider Availability Relocation Which Types Are You Interested In for Your Dependents?* Medical Dental Vision Life Supplemental Only (Critical Illness, Accident, Disability, Hospitalization) Long Term Care Final Expense How many dependents are you seeking coverage for?*Please include your spouse as a dependent. Just my Spouse 1 2 3 4 Who is your dependent's current insurance carrier? SpouseSpouse - Name First Last Spouse - Date of Birth MM slash DD slash YYYY Spouse - Physical Gender Coverage For Child OnlyWhat Has You Looking For Coverage for Your Child? Between Jobs COBRA Coverage Ending Dissatisfied with current plan Family Structure Change Haven't had Health Insurance in a long time Life Event Losing Employer Health Coverage Need Prescription Drug Benefits Price Provider Availability Relocation Which Types Are You Interested In for Your Child?* Medical Dental Vision Life Supplemental Only (Critical Illness, Accident, Disability, Hospitalization) How many children are you seeking coverage for?* 1 2 3 4 Who is your child's current insurance carrier? Dependent 1Dependent 1 - Name First Last Dependent 1 - Date of Birth MM slash DD slash YYYY Dependent 1 - Physical Gender Dependent 2Dependent 2 - Name First Last Dependent 2 - Date of Birth MM slash DD slash YYYY Dependent 2 - Physical Gender Dependent 3Dependent 3 - Name First Last Dependent 3 - Date of Birth MM slash DD slash YYYY Dependent 3 - Physical Gender Dependent 4Dependent 4 - Name First Last Dependent 4 - Date of Birth MM slash DD slash YYYY Dependent 4 - Physical Gender
