Paid Family Medical Leave (PFML) Quote Request Form
Legal Business Name
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Doing Business As (DBA) if Applicable
Federal Employer ID Number (FEIN)
*
Is Payroll Processed for All Employees Under the FEIN Listed Above?
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Yes
No
Total Number of Applicable Federal Employer ID Numbers
*
Additional Federal Employer ID Number (FEIN)
*
Please Specify Applicable Employees on Census File
Additional Federal Employer ID Number (FEIN)
*
Please Specify Applicable Employees on Census File
Additional Federal Employer ID Number (FEIN)
*
Please Specify Applicable Employees on Census File
SIC Code
*
Nature of Business
*
Primary Benefits Contact
*
First Name
Last Name
Primary Contact Email Address
*
example@example.com
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Business Address (No PO Box)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Eligible Minnesota Employees
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The MN Paid Leave Law Defines Minnesota Employees as: Employees who worked 50% or more of the prior calendar year in MN or who live in MN if they did not work 50% or more of the prior year in any one state. Includes Full-Time, Part-Time, Seasonal, Owners and Officers Drawing a Salary, Temporary and Student Workers/Interns.
Additional Quote Options are Just a Few Clicks Away! Would you Like to See a Quote for any other Employee Benefit Plans?
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Yes
No
Do you Currently Offer Life/AD&D, Short Term Disability and/or Long Term Disability Coverage to your Employees?
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Yes
No
Select the Plans you Currently Offer
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Life/AD&D
Short Term Disability
Long Term Disability
Enter Current Life/AD&D, Short Term Disability and/or Long Term Disability Carrier(s)
*
Select Plan(s) to be Quoted:
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Medical
Dental
Vision
Basic Life/AD&D
Short Term Disability
Long Term Disability
Voluntary Life/AD&D
Telemedicine
Paid Leave
Other
Have Questions? Would you Like a Member of our Team to Contact You?
*
Yes
Not at this Time
Contact Name
*
First Name
Last Name
Preferred Contact Method
*
Email
Phone
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Effective Date of Additional Quote(s) Requested (Must be the 1st of the Month):
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-
Month
-
Day
Year
Date
Employer Contribution to Dental Plan Premium
*
100%, Employee pays 0%
Employer and Employee each Pay a Portion of the Premium
0%, Employee pays 100%
Other
Employer Contribution to Vision Plan Premium
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100%, Employee pays 0%
Employer and Employee each Pay a Portion of the Premium
0%, Employee pays 100%
Other
Employer Contribution to Short Term Disability Plan Premium
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100%, Employee pays 0%
100% (Gross-Up)
0%, Employee pays 100%
Other
Employer Contribution to Long Term Disability Plan Premium
*
100%, Employee pays 0%
100% (Gross-Up)
0%, Employee pays 100%
Other
Upload Employee Census Excel File
*
Browse Files
Drag and drop files here
Choose a file
Include Full Name, Date of Birth, Gender, Physical Work Location Zip Code, Job Title and 2025 Annualized Earnings for Each Eligible Employee
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Submitted By
*
First Name
Last Name
Submit
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