Company Name*

Contact Name*

Address

Email*

City*

State*

Zip*

Tel*

Fax

Proposed Effective Date

Current Carrier

Current Renewal Date

Type of Business

More than one location?
YESNO

Number of Full Time Employee's

How many weeks payroll?

# of Cobra's

% of costs to be paid by Employer

Types of Employees to be quoted
AllManagementHourlySalaryNon-Union

Employees Living Out of State
YESNO

Industry SIC Code

Are you interested in other products?
LifeDentalLTD

Number of Employees

Known Medical Conditions: (please describe)