Request A Quote

Request A Quote

Please complete the form below.  We will contact you to review the information provided prior to quoting.  During the review any additional data necessary to complete the RFP will be requested via email. (Census, Plan Design, etc.) 

Please allow 3 business days to complete. 

Agency Name: *
Broker Name: *
Agent Phone: *
 Agent Email: *
Prospect Name: *
Prospect Address: *
City: *
State: *
Zip Code: * (5 digits)
Prospect Phone:
   Business Profile
 Years in Business:  
 Nature of Business:  
Prospect Website Address:
 # of Full Time Employees:  
 Number of Eligible Employees:  
 # Currently enrolled:  
 Proposed Effective Date:  
 Will the Employer payroll deduct the premiums?:
 Does the Employer contribute to the cost?:
 If Yes, % of contribution:
 Is there an Employer/Employee relationship?
 Is this a 1099 or Assoc. group?
 Will the Employer be payroll deduction premium?
   

  Products to Quote:
 MiniMed sm Health Plans:
 Dental/Vision:
 Short Term Disability:
 Term Life:
 Universal Life:
 Critical Illness:
 Accident:
 GAP Plan:
   
 Is this a Takeover?:
.
   If Yes, additional information will be requested.
   
 When do you need the proposal?:  
   
Additional items VBA should know to provide an accurate proposal:

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