BROKER INFORMATION
Name
*
Agency
GROUP INFORMATION
Company Name
*
ZIP
*
City
County
Is the company part of a control group or do they have other affiliated companies?
Yes
No
Coverage provided by a labor fund?
Yes
No
Effective Date
*
Industry (SIC)
*
# of FTE
# Benefit Eligible
*
# Out of State EEs
*
# of 1099s
# of Union EEs
What coverage does the group CURRENTLY offer?
Medical
Disability
Life
Dental
Vision
What coverage does the group WANT to offer?
Medical
Disability(LTD)
Life
Dental
Disability(STD)
Vision
Is there anything special we should know about this group , or special benefits you would like to see?
Yes
No
Submit
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