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
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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
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Does the Company have a GROUP health plan right now?
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Current GROUP Health Insurance Carrier:
Name of health insurance company
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Name(s) of Health Plans Offered:
Name of the insurance plan people enroll into
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Amount Company Pays Towards Health Insurance:
This is usually a flat dollar amount or percentage of premium
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Does the Company have a GROUP disability plan right now?
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Will Company pay towards disability coverage?
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Census Instructions:
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