Please complete this group census as much as possible so that we can better analyze your needs. not all fields are necessary , but more information will give you a better proposal.
Broker Info
Broker:
Agency:
Phone:
Fax:
E-mail:
Client Info
Name:
Type of Business or SIC:
City:
State: Zip Code:
Effective Date:
Needed By:
Current Dental Plan Design
Current Carrier
Current Rates
Single:
Employee + 1:
Employee + Children:
Family:
Renewal Rates
Single:
Employee + 1:
Employee + Children:
Family:
Contribution
Single Rate: $
Employee Contribution: $
Employer Contribution: $
Dependent Rate:
Employee Contribution: $
Employer Contribution: $
Current Participation
Total Number of Employees:
Number of Employees in Plan:
Life & Disability Quotes
Current Group Life Carrier:
Current STD/LTD Carrier:
Requested Plan Design
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.
Preferred Browser
Calendar of Events 