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Request a Quote
Quote
Home
Quote
Company Name:
Company name
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Legal Tax Class
- select a option -
C-Corp
S-Corp
LLC or LLP
Sole Proprietor
Non-Profit 501(c)(3)
State Specific Cooperative
Other / I don't know
- select a option -
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Company EIN:
Tax ID for the company
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Number of Employees:
Total full time employee headcount
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Company Address:
Company's Legal Address
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City:
City
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State:
- select a state -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
- select a state -
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Zip Code:
Zip Code
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Your Name:
Your Name
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Your Email Address:
Your E-mail Address
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Your Phone Number:
Your Phone Number
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Kind of Quote Requested
Health Insurance
Disability Insurance
401K Plan
Payroll or HR Services
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Does the Company have a GROUP health plan right now?
Yes
No
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Field is required!
Current GROUP Health Insurance Carrier:
Name of health insurance company
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[{"field":"current_health_plan","logic":"equal","value":"yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
Name(s) of Health Plans Offered:
Name of the insurance plan people enroll into
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Field is required!
[{"field":"current_health_plan","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
Amount Company Pays Towards Health Insurance:
This is usually a flat dollar amount or percentage of premium
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Field is required!
[{"field":"current_health_plan","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
[{"field":"{quote}","logic":"contains","value":"Health Insurance","and_method":"","field_and":"","logic_and":"","value_and":""}]
Does the Company have a GROUP disability plan right now?
Yes
No
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Field is required!
Will Company pay towards disability coverage?
Yes
No
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Field is required!
Census Instructions:
Please upload a document with each employee's date of birth (or age), gender, tobacco smoking status (i.e. do they smoke?), home zip code, and estimated annual salary
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Field is required!
Census Upload
Upload your documents...
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[{"field":"{quote}","logic":"contains","value":"Disability Insurance","and_method":"","field_and":"","logic_and":"","value_and":""}]
Submit