Submission Request Form

Use the form below to submit a group for quoting. Complete every field that applies, then submit. A PDF copy of your completed Submission Request Form is emailed to our team automatically.

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"*" indicates required fields

Group and Agent Information

Plan Administrator and General Agent

Quoting Options

Site of Care Navigation Analysis*
Contract Type*
Term*
Specialty Drug Coverage*

Employee Census

Carve Out?

Business Information

Which is applicable
Multiple business locations?

Notes

Groups over 75 employees
We will offer a plan match.

Groups under 75 employees
We will offer 6 plan designs.

Employee Eligibility Statements/IHQs for all eligible employees, including those waiving coverage, those eligible for COBRA and those in the waiting period. All questions should be answered completely and accurately and all forms need to be signed and dated by the employee.