GROUP QUOTE REQUEST
Note: Washington State requires 2 eligible employees minimum to receive coverage
COMPANY INFORMATION * indicates required fields
Company Name *
Type of Business *
Group Contact Name *
Contact Title
Address *
City *
State *
Zip *
UBI Number
Phone *
Fax
E-Mail *
Requested Effective Date *
Comments

CURRENT MEDICAL PLAN INFORMATION
Renewal Date
Current Carrier
Individual Deductible

CURRENT DENTAL PLAN INFORMATION
Renewal Date
Current Carrier

CURRENT RATES
	Medical	Dental
	Current Rates	Current Rates
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family