Group Quote Request

Type of Coverage:


(i.e. Health, Life, Retirement)

Company Name

Street Address

City

 

State

 

Zip

 

County

Telephone

Fax

Company Contact

SIC Code (if known)
Nature of Business
Workers Comp Ins.
E-mail Address
Type of Business
If other, please specify:
Current Carrier Information:
Renewal Month
Current Carrier
Plan Type
Current Plan Rates
Individual Husband/Wife Parent/Child Family
Employees Enrolling In Coverage: (Spouse's DOB & # of Children fields are necessary if enrolling them)
Employee Name DOB
(xx-xx-xxxx)		 Gender Family Status Spouse’s DOB
(xx-xx-xxxx)		 # of Children Zip Code
Out of Area Employees: (Spouse's DOB & # of Children fields are necessary if enrolling them)
Employee Name DOB
(xx-xx-xxxx)		 Gender Family Status Spouse’s DOB
(xx-xx-xxxx)		 # of Children Zip Code
Full-time Employees Waiving Coverage/Part-Time Employees: (Spouse's Carrier is necessary if covered under spouse's plan)
Employee Name DOB
(xx-xx-xxxx)		 Gender Part-time
(Yes or No)		 Spouse’s Carrier Zip Code
Yes No
Yes No
Yes No
Please call 814-724-1680 or toll free 800-836-8483 with any questions.

 
       

 

 

 

 

 

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