WEB REQUEST – Group Quote General InformationContact Name*Contact Email* Name of BusinessNature of BusinessAddressCityStateZipCountyBusiness PhoneFaxLife and AD&D CoverageNumber of EmployeesNumber of Employees EligibleCurrent CarrierRenewal DateCurrent RateRenewal RateFlat AmountGroup Health CoverageNumber of EmployeesNumber of Employees EligibleCurrent PlanHMOPOSPPOIndemnityPlan to QuoteHMOPOSPPOIndemnityDesired DeductibleDesired Co-PayDesired Co-InsuranceGroup Dental CoverageNumber of EmployeesNumber of Employees EligibleClass A DeductibleClass B DeductibleClass C DeductibleClass A Co-InsuranceClass B Co-InsuranceClass C Co-InsuranceCalendar Year MaximumGroup Disability CoverageNumber of EmployeesNumber of Employees EligibleCurrent PlanSTDLTDCurrent CarrierRenewal DateCurrent Rates STDElimination Period STDPercentage Payable STDMaximum Benefit STDDuration Benefits STDCurrent Rates LTDRenewal Rates LTDElimination Period LTDPercentage Payable LTDMaximum Benefit LTDDuration Benefits LTDCommentsEmployee census information including Date of Birth, Sex, Job Title and Earnings will be required. Loss Information will be helpful and may be required on groups over 100 lives. Please note any other pertinent information or requests for coveragesDisclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.