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Group Quote Request Form

In order to create a proposal for your company we need some basic information about your company and employees. Most small group carriers require groups to be medically underwritten therefore additional information may be requested.

An asterisk(*) denotes a Required Field.

*Company Name:

Current Carrier:

Contact Name:

Date business was established:

Address:
   

State:

*Zip Code:

Phone number:

FAX Number:

*E-mail:
   

Requested effective date of coverage:

Lines of Coverage:



Employee Demographics:
List all employees on your payroll who work at least 25 hours per week.

 

Gender

Date of Birth

Dependents
to be Covered

Residence Zip Code

Participation Status

Spouse

# Children

Employee #1

Employee #2

Employee #3

Employee #4

Employee #5

Employee #6

Employee #7

Employee #8

Employee #9

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Employee #30

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Employee #50


Beacon Benefit Consulting • Orlando, FL Phone: 407-894-2004 • Jacksonville, FL Phone: 904-215-9955