INFORMATION REQUEST FORM FOR BROKERS Sign up for our news letter Agent name Agency name Phone # E-Mail Address Address 2 City State Zip BROKER INFO Are you in the group benefits, worksite benefits, P&C business or all of the above? Choose PC Business Group Benefits Worksite Benefits All of the above Do you currently sell limited medical plans? No Yes If yes, with which carriers? What is the average size of your current or prospective accounts? Choose 50-499 500-999 1000+ All of the above What, if any, additional products and services are you interested in? (check all that apply) PRODUCTS Term and Permanent Life Insurance Critical Illness Disability Indemnity Dental SERVICES Communication & Enrollment Consolidated Billing Self funded Plan administration Section 125 Plan (Cafeteria) administration AVAILABLE FORMS Please select the forms that you would like. Master Application Employee Application New Business Transmittal Claim Form Change Form Termination Form COMMENTS / QUESTIONS
INFORMATION REQUEST FORM FOR BROKERS
Sign up for our news letter
Agent name Agency name Phone # E-Mail
Address Address 2 City State Zip
BROKER INFO Are you in the group benefits, worksite benefits, P&C business or all of the above? Choose PC Business Group Benefits Worksite Benefits All of the above Do you currently sell limited medical plans? No Yes If yes, with which carriers?
What is the average size of your current or prospective accounts? Choose 50-499 500-999 1000+ All of the above
What, if any, additional products and services are you interested in? (check all that apply)
PRODUCTS Term and Permanent Life Insurance Critical Illness Disability Indemnity Dental
SERVICES Communication & Enrollment Consolidated Billing Self funded Plan administration Section 125 Plan (Cafeteria) administration
AVAILABLE FORMS Please select the forms that you would like.
Master Application Employee Application New Business Transmittal Claim Form Change Form Termination Form
COMMENTS / QUESTIONS
