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.).