Quotes on-line may be a reality in the near future. Most carriers are working on systems to upload and download employee information to their systems. This will give us instant access to plan information and rates. Census information can be e-mailed to us in Microsoft Excel. Please use the following headings below and supply the information requested.

If this is not possible, please fill out the attached census form and fax it to us for quotation. We will contact you upon receipt of your information.

For Medical, Dental, Life, AD&D, Short-Term & Long-Term Disability

Please provide in Excel format:

Employer Information:

• Name
• Address
• Nature of Business
• Contact Person
• Current Rates (copy of most recent bills)
• Renewal Rates
• Current Carrier & Coverages (Booklets or Summaries)

Employee Information:

• Employee Name (List all full-time employees even if they do not take benefits)
• Date of Birth
• Sex
• Occupation
• Coverage requested ( Single, Employee & Spouse, Emp. & Child(ren), Family)
• Annual Salary
• Home Zip Codes
• Date of Hire

Request for Quote:

Company's Name:
City/ State:
Zip Code:
Nature of Business
Date Completed:

Employee's Name

M/F

DOB

Coverage

Annual Salary

Job Description

Home Zip Code

1

M F

E            ES EC F W

2

M F

E            ES EC F W

3

M F

E            ES EC F W

4

M F

E            ES EC F W

5

M F

E            ES EC F W

6

M F

E            ES EC F W

7

M F

E            ES EC F W

8

M F

E            ES EC F W

9

M F

E            ES EC F W

10

M F

E            ES EC F W

11

M F

E            ES EC F W

12

M F

E            ES EC F W

13

M F

E            ES EC F W

14

M F

E            ES EC F W

15

M F

E            ES EC F W

16

M F

E            ES EC F W

17

M F

E            ES EC F W

18

M F

E            ES EC F W

19

M F

E            ES EC F W

20

M F

E            ES EC F W

21

M F

E            ES EC F W

22

M F

E            ES EC F W

23

M F

E            ES EC F W

24

M F

E            ES EC F W

25

M F

E            ES EC F W

26

M F

E            ES EC F W

27

M F

E            ES EC F W

28

M F

E            ES EC F W

29

M F

E            ES EC F W

30

M F

E            ES EC F W

CODES:
M/F - MALE OR FEMALE

Coverage Codes:
E=Single Coverage  ES=Employee & Spouse Only  EC=Employee & Child(ren) only  F=Family  W=Waived Coverage

• Back to Top