FREE and NO OBLIGATION GROUP INSURANCE
(complete and submit or download/print and send by fax or
Company or business name
Fax E-mail (important)
Contact preference? Telephone
Total number of employees to include in quote:
CENSUS : List the age and sex of each employee, plus
what coverage is to be included for dependents. Use the
ee= single employee es= employee+spouse ec=
EXAMPLE: M 35, ESC; F 48, EC. Use as much
space as needed.
Type insurance preferred : Check as many as you
Remember, We listen !... Your comments
will help us design the plan closer to your desires.