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The first step toward more focused employee benefits is as easy as completing the form below. Just fill in the blanks and we will get back to you immediately. Or you can complete our online census or our offline excel spreadsheet and this will allow us to get to work right away!.

Information requests are considered confidential. Your information is never sold, exchanged or otherwise distributed to third parties.

General Information
Your Name *: Title: Company *: Company Size *: # of Eligible Employees 1 - 19 20 - 49 50 - 99 100 - 499 500 - 999 1,000 - 4,999 Over 5,000 Address *: City *: State *: Select State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY ONT N/A Zip *: Phone *: Extension: Email *:
Current Group Health Insurance Information
Carrier name: Policy Expiration Date: Monthly Premium (USD$): Years Insured:
Please give a brief description of your current Group Health plan:
Benefit Desired
We are interested in: Select Interest 100% Employee Paid Plans (Voluntary) Combination Employer/Employee Paid Plans 100% Employer Paid Plans
Are your employees located in more than one state? Yes No
Select the following products you would like information on:
Medical Dental Disability Life Insurance Vision Supplemental Policies Employee Assistance Programs Sec 125/Flexible Spending Accounts Other
Employee Information
Name DOB (eg. 12/30/1970) Zip Gender Dependent Opt Male Female Single W/Spouse W/Child W/Family
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Additional Comments or Questions
Are You Human?