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Group Employee Benefits
Quote Request
Please complete the form and include your employee census and current plan information.
You can either (1) attach your own census, (2) download the census template which is available at the bottom of this page or (3) request that we email you the census template. Please contact us with any questions.
Please note if you need coverage outside of the United States then please go to www.GlobalBRI.com.
Group Employee Benefit Coverages to be quoted:
Health
Life / AD&D
Disability
Dental
Vision
Legal Services
401(k)
Free Drug Discount Card
Voluntary Benefits
Long Term Care
Business Travel Abroad
Employee Benefits Abroad
Trade Association Membership Affiliation (if applicable):
Organization / Company Name:
Industry / Business Type:
Contact Name:
Telephone:
Fax:
Email:
Website:
Address:
City:
State:
Zip Code:
Desired Effective Date:
Total number of eligible employees:
Is there group coverage currently in place?:
Please select...
Yes
No
If yes name of Group carrier:
Yes I'd also like information on the below products:
Workers Compensation
General Liability
Directors & Officer Liability
Umbrella
Business Personal Property
Key Man
Business Auto
Alarm/Security Liability
Professional Errors & Ommissions
Tools & Equipment
Product Inventory & Supplies
Alarm Liability Errors & Ommissions
Data Breach/Idnetity Theft
Services & Liability
Buildings & Property
Event Cancellation
Event Liability
Business Insurance Abroad
Other:
Employee Census: You can either (1) upload your own census (2) download the census template which is available at the bottom of this page or (3) request that we email you the census template.
Would you like us to email a census form to you?
Please select...
Yes
No
Attach your census - file upload:
Current Plan Information:
Attach your current plan information and claims history (if available) - file upload:
Comments or Questions:
Comments or Questions:
Do not enter anything in this field:
Download Employee Census Template
Employee Census - Click here to download employee census (excel)
