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Group Benefits

Group Quote Request

 

 

If you have any questions regarding the status of your quote request, please contact the quoting department:

Email: quotes@resourcebrokerage.com
Phone: 847-605-1200

*Required Fields

Broker Information
First Name: *
Middle Initial:
Last Name: *
Email: *
Phone: *
Alternate Number:
Preferred Method
to Receive Quote: *		  

Company Information
Desired Effective Date of Coverage:  (M/D/YY)
Company Name: *
Type or Description of Business: *
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?:
Maternity?:
 
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