Small Group Quote Request Form

For employers with 2 - 50 employees.

The primary address of the business applying for coverage must be located in Dane, Columbia, Iowa, Jefferson, Jueau, Grant, Lafayette or Sauk County.

Company Name*

Requested Effective Date*

Date

Contact Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.

Email Address*

example@example.com

Current Carrier*

Agent/Agency*

Name of Person Requesting Quote*

First NameLast Name

Email of Person Requesting Quote*

example@example.com

Please complete census by clicking the link below to download the Small Group Request for Proposal Spreadsheet. Fill out the information in the spreadsheet, save a copy to your computer and upload in the File Upload field on the next page.

Please note, we are only accepting the following file types for these requests. Please, do not convert into a different file format, as the form will not accept it:

xls
xlsx
csv

Click Here for the Small Group Request for Proposal Spreadsheet