Group Proposal Request
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Group Name:
Group Phone:
Group Email:
Group Headquarters City:
Group Headquarters State:
Group Main Zip Code:
Does the group have prior coverage?
Yes
No
Requested Effective Date:
SIC Code or Industry Description:
3 or 4 tier Rate Request:
Due Date:
Groups current premiums:
Groups renewal premiums:
Groups current carrier:
How many employees do you project will participate?
Will the company pay for some or all of the employee's premium?
Yes
No
How many total full-time employees are there?
Will the company pay for some or all of the dependent's premium?
Yes
No
Other comments/notes:
Do you work with a broker?
Yes
No
If so, can we contact them?
Yes
No
Broker Name:
Broker Phone:
Broker Email:
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