Business Group Insurance and Employee Benefits


BUSINESS SUBMISSION FORM
* denote what should be required fields.

* Company Name
* Contact Name
  Your Title
  Type of Business
  Address:
* City
* State
* Zip
* Phone
  Fax
* E-mail
* Desired Coverage Effective Date
* Number of Employees
CURRENT INSURANCE INFORMATION:
* Existing Carrier
* Type of Coverage Desired Health Insurance
Dental
Life
AFLAC
Disability
PEO (Employee Leasing)
* What is most important to you? Better Service
Lower Premiums
Lower deductibles/copays
No referrals
Prescription co-pays
Bigger choice of physicians
Multiple plan choices