Health Benefit Quote Request
Company Name
*
Company Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Tax ID Number
*
What type of business do you have
*
Do you have more than one location
*
Yes
No
Please list the locations
How many full time employees does the company have:
How many Part Time employees does the company have:
For Health Benefit purposes, employees who work 30 or more hours per week will be considered full time.
How many hours must an employee work to be considered for benefits:
PLEASE NOTE THAT UNDER THE A.C.A. EMPLOYEES WHO WORK 30 OR MORE HOURS A WEEK ARE CONSIDERED FULL TIME AND ARE SUBJECT TO BENEFITS
Does the company currently offer benefits:
Yes
NO
Which benefits would you like our agency to quote:
*
Health
Dental
Vision
Group Life
Employer paid short term disability
Employer paid long term disability
Voluntary short term/ long term disability
Accident, cancer, critical illness, hospital, voluntary life
Pet Insurance
Which benefits does the company offer at this time:
*
Health
Dental
Vision
Group Life
Employer paid short term disability
Employer paid long term disability
Voluntary short term/ long term disability
Accident, cancer, critical illness, hospital, voluntary life
Pet Insurance
When does your benefits renew:
Do you have a Section 125 Resolution in place:
Yes
No
Do you have a current WRAP Document in place:
Yes
No
Can you provide our agency with a census: ( we do need a census to quote)
Yes
No
You can upload the supporting documents here:
Browse Files
Drag and drop files here
Choose a file
documents would include your current benefit invoices
Cancel
of
census
Do you currently have an onboarding-benefit enrollment platform:
*
Yes
No
Which platform are you using:
EASE
Employee Navigator
Paychex
Paycor
Rippling
ADP
Bernie Portal
Other
What is your availability to have a discussion on your request:
Person completing form
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please verify that you are human
*
Submit
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