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Group Disability Insurance Quote Request

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Legal Name of Business:
Contact Name:
Address:
City:
State:	Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
E-mail Address:

Type of Business
Type of Business:
No. of Full Time Employees:	No. of Part Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Health Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:	Premium Amount: $
Years Insured:
Please give a brief description of your current Group Health plan:

Benefits Desired
Major Medical Deductible:		Optional Pregnancy Coverage:	Yes No
Dental Coverage:	Yes No	Supplemental Accident Coverage:	Yes No
Disability Insurance:	Yes No	PCS Card: (Prescription Disc Option)	Yes No
Group Life Insurance:	Yes No	PPO Option:	Yes No
Amount:	$	HMO Option:	Yes No

Employee Information
Please list all employees you wish to cover:
Employee Name	Job Title	Date of Birth	Salary	Sex	Dependent Status
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
				Male Fem
If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or e-mail an additional listing.

Additional Comments or Questions

Please click the "Submit Quote" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.