»


General Information
Legal Name of Business:
Contact Name:
Address:
City:   State:   Zip:
Business Phone:   Fax:
Best Time To Call:  AM   PM
Contact Email Address:

Employee Information
Please list all employees you wish to cover:
Employee
Date of Birth
month/day/year (i.e. 10/24/1968)
Sex
Dependent Status*
Emp # 1
Male
Female
E
ES
EC
F
Emp # 2
Male
Female
E
ES
EC
F
Emp # 3
Male
Female
E
ES
EC
F
Emp # 4
Male
Female
E
ES
EC
F
Emp # 5
Male
Female
E
ES
EC
F
Emp # 6
Male
Female
E
ES
EC
F
Emp # 7
Male
Female
E
ES
EC
F
Emp # 8
Male
Female
E
ES
EC
F
Emp # 9
Male
Female
E
ES
EC
F
Emp # 10
Male
Female
E
ES
EC
F
Emp # 11
Male
Female
E
ES
EC
F
Emp # 12
Male
Female
E
ES
EC
F
Emp # 13
Male
Female
E
ES
EC
F
Emp # 14
Male
Female
E
ES
EC
F
Emp # 15
Male
Female
E
ES
EC
F
Emp # 16
Male
Female
E
ES
EC
F
Emp # 17
Male
Female
E
ES
EC
F
Emp # 18
Male
Female
E
ES
EC
F
Emp # 19
Male
Female
E
ES
EC
F
Emp # 20
Male
Female
E
ES
EC
F
Emp # 21
Male
Female
E
ES
EC
F
Emp # 22
Male
Female
E
ES
EC
F
Emp # 23
Male
Female
E
ES
EC
F
Emp # 24
Male
Female
E
ES
EC
F
Emp # 25
Male
Female
E
ES
EC
F
Emp # 26
Male
Female
E
ES
EC
F
Emp # 27
Male
Female
E
ES
EC
F
Emp # 28
Male
Female
E
ES
EC
F
Emp # 29
Male
Female
E
ES
EC
F
Emp # 30
Male
Female
E
ES
EC
F

* E = Employee
ES = Employee + Spouse
EC = Employee + Child(ren)
F = Family
NOTE: If you have more than 30 employees please send the additional information (in the above format) to your personal broker either via fax at 303-861-5006 or via e-mail listed below:

Your Business
Type of Business:
Standard Industry Code (if known):
Class Code:
1: 2: 3: 4: 5:
Payroll:
1: 2: 3: 4: 5:
Rate:
1: 2: 3: 4: 5:
SUTA Rate
Number of losses over $10K for last 3 years:
Frequency of losses over last three:

Benefits Desired
HMO: yes   no
PPO: yes   no
Dental Coverage: yes   no
Vision Insurance: yes   no
Additional Comments
Please give any additional comments you feel appropriate for this quotation.
If you have additional information where there was not enough space, please enter that here.
By clicking the "Submit Quote" button you understand that this is only a request for a quote, NOT a policy or insurance binder. No coverage will be provided until a policy has been issued or accepted by the selected company(s).

NOTE: Final rates are based on final enrollment

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.
   

303.771.4445

About Us | Announcements | Career Opportunities | Contact Us | Partner Opportunities | Home
Outsource Accounting | Technology Consulting | Technology System Sales | Recruiting Solutions | Professional Resourcing | What Is A PEO? | One Point HR Solutions | Other HR Solutions | Request an Analysis | Employee Benefit Programs