If you would like to receive a no obligation quote on a group insurance plan feel free to call us, email us, or fax your information to our office. All information submitted will be treated confidentially. The columns that are needed for a health or dental insurance quote are: sex, date of birth, spouse date of birth, # of children, and home zip code.

NAME (optional)

SEX

DATE OF BIRTH

SPOUSE DATE OF BIRTH

# OF CHILDREN

HOME ZIP CODE

LIFE AMOUNT

OCCUPATION

SALARY

Company Name: ___________________________________________

Contact Person: ___________________________________________

Address: ___________________________________________

___________________________________________

Phone Number: ___________________________________________

Fax Number: ___________________________________________

Return Form to: Group Benefits, 21 Nob Hill Drive, Lower Level, St. Louis, MO 63138

PH: (314) 438-0222 FAX: (314) 355-4512 EMAIL: RobynHamlin@grpbenefits.net