Agent Name
Agent Phone Number
Agent E-mail
Name of Group
Group Address
Address (cont.)
Group City
Group State/Province
Group Zip/Postal Code
Country
Type of Industry
Business Entity Type

Sole Proprietor
C Corp
LLC
Not-for-profit

Partnership
S Corp
Church
Government
Number of Employees
Are all employees at one location? YesNo
If not, please list all locations including city, state and zip code
What type of plan are you interested in?
POP FSA HRA HSA COBRA SSB
Single Source Billing
Is this a new plan or an amendment to an existing plan? NewExisting
Benefits under this plan will include:
(required for POP or FSA)
Medical Expenses Dependent Care Expenses Health Premiums Dental Premiums Other Premiums
If Other Premiums, please specify
Any other questions or comments that will help process your request?

If you have any questions regarding this form, please contact us.

If you prefer, you can print out a copy of this form to fax or mail in using the link below.

Proposal Form (PDF Format)