Benefits & Financial Services Request for Quote
General Information
Legal Business Name
FEIN#
Location / Office Address
City
State
Zip
Preferred Mailing Address
City
State
Zip
Primary Contact Name
Phone
Email
Date company was founded
How did you hear about us?
How many full-time employees?
# of W2
# of 1099
Do you currently have a benefits package set up?
Yes
No
What is the renewal date of your program?
Are you currently working with any other brokers regarding benefits?
Yes
No
How has your experience been to date?
What kind of benefits package are you looking to roll out? (Medical, dental, life, 401k, etc.)
What prompted you to start exploring benefits at this time?
Do you have an idea of how much the company would like to contribute towards the benefits offering? (100%, 75%, 50%, etc.)
Do you have Payroll and HRIS in place currently?
Yes
No
Realistically, how fast do you expect to grow over the next 12-24 months?
Who currently handles HR functions (Payroll, etc.)?
Do you currently have an employee and dependent census?
Yes
No
If yes, please upload
here
so we can get an idea of your population to start working on quotes.
You may also download a census template
here