Group Health and Dental Insurance, We provide personal service to employers and their employees. We work with major insurance companies to provide you with low cost insurance and good benefits.
Group Benefits, Inc.
21 Nob Hill Drive, Lower Level
St. Louis, MO  63138
PH:  314-438-0222
FAX:  314-355-4512
Web:  www.grpbenefits.net

REQUEST A GROUP INSURANCE QUOTE

(This form is for Employers in the St. Louis Missouri Illinois Metro Area)

We offer 3 options to complete this form.
  • Download the Word document Right click the link and save as. Complete form, then fax, mail or email to Group Benefits.
  • Download the PDF document Complete form, then fax, mail or email to Group Benefits.
  • Or complete the online form below to submit  your request electronically to Group Benefits, Inc.

EMPLOYER INFORMATION

Contact Person:
Email address:
Company Name:
Company Address:
City State and Zip:
Phone:
Number of Employees:
Company Industry:
Current Insurance Company:
Are you aware of any major health conditions? If so, what are they? If none, indicate none in the comment area.
Comments

 

EMPLOYEE CENSUS DETAIL

  Name of Employee (Optional) # Hours worked a week Date of Birth or Age Sex
(M/F)		 Spouse Date of Birth or Age Number of Children Home Zip Code
1
2
3
4
5
6
7
8
9
10
11
12
13
14
 

If you have 15 or more employees you have several options.  You can complete this form more than once, email us and attach your census with an Excel or Word document, or fax the information to our office in your own format.