Employee Benefits Form

Employee Benefits Form

Part 1 - Company Information

Company Information

Part 2 - Plan Information

Life Insurance

Weekly Income

If yes, please fill out the following:

Long Term Disability

If yes, please fill out the following:

Health Benefits

How much is the annual deductible?

Re-imbursement factors:

Dental Benefits

If yes please provide the following information

Annual deductible:

Reimbursement factors:

General Information

Part 3 - Employee Information

A maximum of fifteen employees are allowed for a Quick Quote. All fields are required. Employee names can optionally be anything you want, as long as something is entered (e.g. 1, 2, etc.).