1. The Basics

Company Zip Code *

Company Name *

Contact Name *

Contact Email * 🛈

Contact Phone * 🛈

2. Employees to Quote

Number of Employees *

For companies with 11+ employees, we recommend a secured census (in any format you currently have it) to make it easier. Just select "10+" and submit - we'll send over a secured census form/email. This saves you a lot of hassle in filling out the online form for so many employees. Just trying to make shopping for group health easier!

Employee #1

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

Employee #2

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

Employee #3

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

Employee #4

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

Employee #5

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

Employee #6

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

Employee #7

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

Employee #8

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

Employee #9

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

Employee #10

Name or Initials *

Age *

Dependents? *

Spouse Age (if quoting)

# of Children (if quoting)

4. Current Coverage (optional)

List current Carrier, Monthly Rate, and Plan. We can use this to price-shop the market for comparable/better rates. 🛈

Current Company Contribution 🛈

Monthly Target Budget 🛈

Do you currently use online Benefit HR system? If so, which one? 🛈

Any doctors and/or hospitals to check in terms of network status? (not required but a quick request from employees is a huge help) 🛈

What to Expect:

Complete Proposal - Usually received within 24 hours (business hours 9am-5pm Monday-Friday) of form submittal.

It will include:

Summary Report - shows best priced plans across all available carriers at the Silver level (apples to apples). This helps us figure out which carrier is priced best since plans are standardized.

Employee Worksheet - plan and rate detail based on your desired employer contribution for each employee for the best priced carrier determined by Summary report above.

Our Analysis - in the email, we'll target specific options that offer a cost/benefit value based on 25 years of experience in the employer market and explain how to get the most out of these. Our services are 100% FREE to you. Zero cost.

Let us get to work! Let's find rates that allow you to start or continue offering employee benefits!

Save & Return

Save your progress and complete this form later. (optional)