Quick Quote / Response Form
How did you hear about us?
How would you like to receive your quote?
Company:  Phone: - - Ext:  
Address: Fax: - -  
  E-mail:
City: State:       Zip:
Description of business:
       
Total # of employees:
 
Please check which coverage you would like us to quote
 
Major Medical Insurance Individual Travel Medical Insurance
Dental Insurance Group Travel Medical Insurance
Short Term Disability Voluntary employee pay all Dental Insurance
Long Term Disability Voluntary employee pay all Short Term Disability
Life Insurance Voluntary employee pay all Long Term Disability
Long Term Care Insurance 401K Plans
Additional Services:
Cobra Administration
Section 125 premium only plans
   
For health insurance only!  
Do you have a current health insurance plan?
This current health insurance plan is a:
Policy Renewal Month:
Policy renewal date:
Name of health insurance carrier:
Current monthly premium: Individual: Couple:
Employee & Child(ren) Family:
For dental insurance only!  
Do you have a current dental plan?
Is this plan voluntary employee pay all?
Policy Renewal Month:
Policy renewal date:
Name of dental insurance carrier:
Current monthly premium: Individual: Couple:
Employee & Child(ren) Family:
     
Important: Salary information is ONLY required when requesting either LIFE or DISABILITY coverage
 
Date of Birth Gender Zip Code Coverage Enrolled Salary Occupation
Employee 1
Employee 2
Employee 3
Employee 4
Employee 5
Employee 6
Employee 7
Employee 8
Employee 9
Employee 10
Employee 11
Employee 12

 
Run out of room? Fax your census to 978-964-0777 or email it to sal@flexiblebenefitsolutions.com