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Company Name:
Contact Name:
Address:
Email:
City:
State:
Zip:
Tel#:
Fax#:
Proposed Effective Date:
Current Carrier:
Current Renewal Date:
Company Structure:
Sole Proprietor
Corporation LLC
Partnership
Other
Type of Business:
More than one location?
Yes
No
Number of Full Time Employee's (30+ hours/ week)
How many weeks payroll?
# of Cobra's:
% of costs to be paid by Employer:
% of Employee Costs
% of Dependent Costs
Types of Employees to be quoted:
All
Management
Hourly
Salary
Non-Union
Employees Living Out of State:
Yes
No
Industry SIC Code:
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Known Medical Conditions: (please describe)
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