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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
Current Group Health Insurance Information
Benefit Desired
Yes No
Medical Dental
Disability Life Insurance
Vision Supplemental Policies
Employee Assistance Programs Sec 125/Flexible Spending Accounts
Employee Information
Name DOB
(eg. 12/30/1970)
Zip Gender Dependent Opt
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Additional Comments or Questions
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Contact Information:

Landmark Insurance Associates, Inc.

5388 East Mountain Street
Stone Mountain, GA 30083

Tel: 770-498-6969
Fax: 770-498-1969