BBG - Business Benefits Group

Quote for Commercial Insurance

*Your Name:

*Company Name:

*Industry/Nature of Business:

*Company Address:

*Your Position:

*Email Address:

*Phone Number:

Fax Number:

Best time to reach you:

*How did you hear about BBG?

Does your company currently have company benefits?

Corporation

Partnership

Sole Proprietorship

LLC

Number of owners:

*Number of employees:

Total payroll amount of owners

Total payroll amount of employees

Total annual gross receipts:

Number of years of experience in this business

Number of years operating under current business name:

Other business names used during the past 5 years:

Were there any losses or claims in the last 5 years?

Yes

No

*Are you currently insured?

Yes

No

If yes, who is your current carrier?

How much are you paying now?

What is your current Liability Limit?

When does your current plan expire?

Additional remarks or requests:

Provide Census Information (submit online or download census form to submit by fax or email)

*Check all items of interest:

Workers Comp
Business Liability
Directors and Officers
Errors and Omissions
Commercial Property
Commercial Auto
Commercial Umbrella
Performance Bonds
Builders Risk
Professional Liability

Group Health
HSAs/HRAs
Group Dental
Group Life
Group Vision
Group Long-Term Care
Group Disability
Key Employee Insurance
Section 125/ Cafeteria Plans
Flexible Spending Accounts
Retirement Plans
Voluntary Benefits

Medical
Self

Spouse

Children

Dental
Self

Spouse

Children

Term Life Insurance
Self

Spouse

Children

Whole Life Insurance
Self

Spouse

Children

Disability
Self

Spouse

Long-Term Care
Retirement Planning
Auto Insurance
Homeowners Insurance
Renters Insurance
Watercraft Insurance

Employee Handbooks
Affirmative Action Plans
FMLA, COBRA & HIPAA
Performance Management
HRIS Systems
Enrollment Administration
Billing Reconciliation
Employee Training
FLSA Compliance
5500 Preparation

Other -

*Your Name:
*Company Name:
*Industry/Nature of Business:
*Company Address:
*Your Position:
*Email Address:
*Phone Number:
Fax Number:
Best time to reach you:
*How did you hear about BBG?
Does your company currently have company benefits?	Corporation Partnership Sole Proprietorship LLC
Number of owners:
*Number of employees:
Total payroll amount of owners
Total payroll amount of employees
Total annual gross receipts:
Number of years of experience in this business
Number of years operating under current business name:
Other business names used during the past 5 years:
Were there any losses or claims in the last 5 years?	Yes No
*Are you currently insured?	Yes No If yes, who is your current carrier? How much are you paying now? What is your current Liability Limit? When does your current plan expire?
Additional remarks or requests:
Provide Census Information (submit online or download census form to submit by fax or email)

*Check all items of interest:
Workers Comp Business Liability Directors and Officers Errors and Omissions Commercial Property	Commercial Auto Commercial Umbrella Performance Bonds Builders Risk Professional Liability

Group Health HSAs/HRAs Group Dental Group Life Group Vision Group Long-Term Care	Group Disability Key Employee Insurance Section 125/ Cafeteria Plans Flexible Spending Accounts Retirement Plans Voluntary Benefits

Medical Self Spouse Children Dental Self Spouse Children Term Life Insurance Self Spouse Children	Whole Life Insurance Self Spouse Children Disability Self Spouse Long-Term Care Retirement Planning Auto Insurance Homeowners Insurance Renters Insurance Watercraft Insurance

Employee Handbooks Affirmative Action Plans FMLA, COBRA & HIPAA Performance Management HRIS Systems	Enrollment Administration Billing Reconciliation Employee Training FLSA Compliance 5500 Preparation

Other -