Group Benefits Quote Request

3205 68th St SE Caldonia, MI 49316

www.glibrokers.com

616-656-5555
Group Benefits Quote Request
- Company Name*
- Contact First Name*
- Contact Last Name*
- Company Address*
  Street Address, City, State, Zip
- County*
  County
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email*
  example@example.com
- SIC Code or Nature of Business*
- Total Number of Employees*
- Total Number of Full-Time Employees*
- Do you currently have employee benefits?*
  
  YesNo
- Current Insurance Carrier
- Payroll Frequency*
- Please select the benefits you are interested in*
  
  MedicalDentalVisionGroup LifeVoluntary LifeShort-Term DisabilityLong-Term DisabilityAccidentOther
- Please select other services you are interested in
  
  Payroll SystemsCobra AdministrationTax-StrategiesOther
- Would you prefer paper forms or electronic ones?*
  
  PaperElectronicNot Sure
- Employer Desired Spending Plan
- Requested Effective Date of Insurance*
  
  MonthDayYear
- Preferred Method of Contact*
  
  PhoneEmailEither
- Best Time to Conact*
  
  MorningAfternoonEither
- Since insurance rates vary by age, we require at least the date of birth for all employees eligible for insurance (those working full-time) to provide the most accurate quotes.
  
  1. Please upload a census of current employees. Please include the following information or click here to download our template
  - First Name
  - Last Name
  - Date of Birth
  - Relationship (Employee, Spouse, Child)
  - Status (Enrolling, COBRA, Waiving)
  - Gender
  - Home Zip Code
  - Job Title
  - Annual Income (if seeking disability quotes)
- 2. Click here to upload your file securely
- If you prefer, you can simply provide the average age of your employees, and we can offer a range of prices based on that information.
- Average age of Employees
- Comments/Special Requests
- Should be Empty: