Group Information Form
Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.
A) Employer Information
B) Current Medical Coverage
C) Employee Statistics
D) Quote Request
Base Life & AD&D
Optional Life & AD&D
Large Groups - Sections E-F are required for large groups (51+ ATNE). Optional for small groups.
E) Carrier History - For Last 5 Years. Medical carrier history required. Ancillary carrier history helpful.
F) Group Medical Plan Questions
1. Are any classes of full time employees excluded from coverage? If so, please explain. *
2. Are retirees eligible for coverage? If so, how many are under 65? *
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
Per the terms of our
we will not resell your information to any third-party.