Thank you for your interest in obtaining a quote through Employer Benefit Consultants. We need three things from you to properly process your quote request.

1. Fill out and submit the proposal request to the right.

2. Download the Employer Census Form

This form is in Microsoft Excel format. You can fill out the form using Excel and fax it to us at 740-549-3509.

Click here to download the Employer Census Form

The form will be downloaded to your computer. Right click the link and choose "Save Target As" to choose the destination.

3. Download the Questionnaire Form

Less than 50 employees - This form is in Microsoft Word format. You can fill out the form using Word and fax it to us at 740-549-3509.

Click here to download the Questionnaire

The form will be downloaded to your computer. Right click the link and choose "Save Target As" to choose the destination.

More than 50 employees - This form is in Microsoft Excel format. You can fill out the form using Excel and fax it to us at 740-549-3509.

Click here to download the Gatekeeper Questionnaire

The form will be downloaded to your computer. Right click the link and choose "Save Target As" to choose the destination.

 


Proposal Request

To receive an insurance quote for health insurance plans, please provide:

Name of Company:
Contact Person:
Company Address:
Type of Business:
Phone Number:
Fax Number:
E-Mail Address:

Current Plan Info:

Carrier Name:
Type of Plan:
$ Co-insurance amount:
$ OV co-pay:
$ Deductible (Indiv/Family):
$ Stop Loss (Indiv/Family):
$ Drug Card co-pay:
   

 


Employer Benefit Consultants • 7888 Royal Park Drive • Lewis Center, Ohio 43035

Direct 614-332-9975 • Fax 740-549-3509


© 2003 Employer Benefit Consultants • Site Design by Highway Internet