If you would like to receive a no obligation quote on a group insurance plan you will need to provide us with your census information.  You can send this information by email, fax, regular mail, or use our secure online quote request.  All information submitted is treated as confidential.  The columns that are required  for a health or dental quote are:  gender, employee and spouse date of birth, # of children, and home zip code.  For a short or long term disability quote we need gender, employee date of birth, home zip code, occupation, and salary.  For a life insurance quote we need gender, employee date of birth and life amount if you want different amounts for each employee or salary if the life amount will be based on their annual salary.  

Name
(optional)

Gender
(Sex)

Employee
Date of Birth
or Age This Year

Spouse
Date of Birth
or Age This Year

# of
Children

Home
Zip Code

Occupation
or Job Title

Life
Amount

Salary
(weekly, monthly, or annual)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Any major health  conditions? (maternity, heart, blood pressure, headaches, cancer, diabetes, kidney, liver, mental, nervous, alcohol, drug)  If so please provide treatment and medications.

 
 
 
 
 



 

Company Name:  
Contact Person:  
Address:  
City, State  Zip  
Phone:  
Fax:  
Email:  


Send form to:  
Robyn Hamlin, Group Benefits, Inc., 21 Nob Hill Drive, Lower Level, St. Louis, MO  63138
PH:  314-438-0222  Fax:  314-355-4512