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Cobra Administration Employee Handbook Benefit Administration Software Benefit Statements Section 125

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Individual

Individual Life Group under 20 Group 20 +

Request a Quote

Group under 20

Group Insurance Quote Form (Available for Connecticut, Massachusetts, and New York Only)

Use this form only if you have less than 20 employees. If you have more than 20 employees, please download a blank census and make copies as necessary or contact our office.

Please check which coverage(s) you would like to receive a quote for.

Medical Insurance	Group STD
Dental Insurance	Group LTD
Group Life Insurance	Other :

COMPANY :
CONTACT NAME :
TITLE :
COMPANY ADDRESS :
CITY :
STATE :		(Available for Connecticut, Massachusetts, and New York Only)
ZIP CODE :
PHONE NUMBER :
FAX NUMBER :
EMAIL ADDRESS :
CURRENT CARRIER(S) :
RENEWAL DATE :
NUMBER OF FULL-TIME EMPLOYEES :

Please complete the census below based on your current employees 1 thru 10. Please list all eligible employees, indicating those who are waiving coverage.
EMPLOYEE NAME	DATE of BIRTH	GENDER	OCCUPATION	INCOME	COVERAGE STATUS

Click CONTINUE to submit this