Group Quote Request

If you have any questions regarding the status of your quote request, please call:
Name: Susan Garcia
Email: sgarcia@resourcebrokerage.com
Phone: (847) 605-1200 Ext. # 0030 *Required Fields

Broker Information
First Name: *
Middle Initial:
Last Name: *
Email: *
Phone: *
Alternate Number:
Preferred Method
to Receive Quote: *		  
UPS will not deliver to a Post Office Box

Company Information
Company Name: *
Type or Description of Business: *
Total Number of Employees
Total Number of Insured Employees (medical & life)
Main Business Address:
City:
State:
Zip: *
Main Business Phone: *
Note: We will never call your client, the phone number is required
for BC/BS and Humana data entry/filing/SIC code purposes ONLY!
Number of Business Locations Applying

Group Information
Carrier(s) to be Quoted: *
Plans: *
Check all plans that are desired
Dental?:
If yes, please answer the following:
Is this a Takeover Group?
Is this Ortho coverage?
Maternity?: