Request For Information

Please complete the form below or click here for a printable form to fax (724-283-1367) or email.

Company Name	# Eligible Employees	# Covered Employees
Address
City	State	Zip
Contact Name	Title
Phone	Fax
Type of Business	SIC (if known)
Email Address

Please check the box(s) that correspond to the quotes you are requesting.

HealthDentalVisionLifeShort Term DisabilityLong Term Disability

Current Insurance:

Name: Plan Name: Plan Description:

Rates: Employee Only
$

Employee + Child
$

Employee + Children
$

Employee + Spouse
$

Family
$

Employee Census Instructions

To enter employee information, enter employee information first and click “Add Employee…” button then enter each employee and add separately. You must click the “Add Employee…” button for each entry. To complete request click the “Submit Request for Quote…” button.

For groups over 50 please contact Scott Ingalls at 877- 285-6446

Please complete the following information. If Coverage Type of Parent + Children or Family is chosen, please indicate the number of children.

Name	Date of Birth	Sex	Zip Code of Residence	Coverage Type	# of Children