Quote for Group Benefits

*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?	Select from Below Yellow Page Ad Internet Search Employer Referral Mike Gore Other
*Does your company currently have company benefits?	Yes No If yes, who is your current carrier: When does your current plan renew:
*Total number of employees in your company:
*Approximate number of employees to be insured:
Current likes or dislikes about your coverage:
Additional remarks or requests:
Provide Census Information (submit online or download census form to submit by fax or email)
*Check all items of interest:
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
Workers Comp Business Liability Directors and Officers Errors and Omissions Commercial Property	Commercial Auto Commercial Umbrella Performance Bonds Builders Risk Professional Liability
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 -

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