Group Quote Request

Group Benefits Quote Request

Please complete this group census as much as possible so that we can better analyze your needs. NOTE: not all fields are necessary, but more information will give you a better proposal.

  • Broker Info

  • Client Info

  • Current Dental Plan Design

  • Preventative %Basic %Major %Ortho %
  • Preventative %Basic %Major %Ortho %
  • Per person / Per year
  • Lifetime Max.
  • Current Rates

  • Renewal Rates

  • Contribution

  • Current Participation

  • Life & Disability Quotes

  • Requested Plan Design

  • Salary XFlat Amount $
  • Census Entry

    If you are requesting a Life or DI quote, please include Census Data with M/F, DOB, salary, and class ~or~ Fax census to 603-418-0853 and refer to online request in Subject.
  • Accepted file types: pdf, txt, doc, xls, jpg, Max. file size: 50 MB.
    You can upload a census file securely with this form. File types: PDF, TXT, DOC, XLS, JPG