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RECEIVE A QUOTE

Please complete the form below to receive a free quote. Please include a return phone number and notes on when is the best time to contact you.  

PRINTER FRIENDLY VERSION

Company Name:
Contact Name: 
Address: 
Address (cont'd): 
City:    State: 
Zip:    Phone: 
Work Phone:    Fax: 
Email: 
Type of Business: 
Year Established:  

 

Enter Your Census Data

[If you have more than 9 employees:  fill out all employee fields on this form and click the "Submit" button. Return to the form, enter just your company name, the remaining employee information, and click "Submit" again.  You may repeat the process as often as necessary.]

Name Age DOB
(mm/dd/yy)		 Sex Spouse No. Of Children
1.  M
F 		Y
N
2.  M
F 		Y
N
3.  M
F 		Y
N
4.  M
F 		Y
N
5.  M
F 		Y
N
6.  M
F 		Y
N
7.  M
F 		Y
N
8.  M
F 		Y
N
9.  M
F 		Y
N

 

Type of Coverage Desired?

PPO (Preferred Provider Organization): Yes No    
HMO (Health Maintenance Organization): Yes No    
POS: Yes No    
Disability: Yes No    
Dental: Yes No    
Life Insurance: Yes No    
           

 

 

 


 

P.O. Box 4849
Wilmington, NC 28406
Phone: (910) 799-5453
Fax: (910) 313-2722
Toll Free: (866) 799-5453
531 Keisler Drive Suite 104
Cary, NC 27511
Phone: (910) 799-5453
Fax: (910) 313-2722
Toll Free: (866) 799-5453
 
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