Employee Benefits Intake

Employee Benefits Intake

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Primary Contact*

First NameLast Name
Phone Number*
Prefered contact number.
E-mail*
Job Title*
Company Info

We'll need some information to provide you with a quote, such as your company's legal name (not DBA), industry, and zip code.
Legal Company Name*
Include Coproration, LLC, etc
Years In Business*
Type of Business or Industry
I.e., Construction, Restaurant, Dr's Office, etc.
Number of Employees
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code

Employee Census
For each employee, include the Employee's name (plus any dependents including gender, relationship & DOB) and Type of Coverage (Medical, Dental, Vision, Life, etc.) Level of Coverage (i.e., Employee only, Employee & Spouse, Employee & Children, or Family), Date of Birth(s), Gender(s), and Zip code.

Note: We will need Job Titles and Salary information if you want us to quote Disabiilty or Life coverages.
Download a blank census to complete and return if you need an example.
Are you ready to upload a census now?

Yes, I'd Like To Start The Quoting ProcessNo, Let's Talk First

Company Info