Request For Information (Group Benefits)

Please complete all the fields on this form.

* required

Company Infomation

Company Name *

Address *

Postal Code *

Phone *

Fax

Email *

Requested by *

Position *

Who should be contacted about the proposal? *

Who will make purchase decision? *

What is the nature of the business? *

How long has company been in business? years

How many employees will be covered? * (minimum number of employees - 3)

Do you have any benefits now? Yes

If yes, who is the current carrier?

Do you have an advisor? Yes

If yes, who?

Additional Comments