Company information
Tell us about the business requesting coverage.
Business
Coverage basics
Current carrier (if any)
Please complete the required fields marked with *.
Employee census
Add a row per employee, then use "+ spouse" or "+ child" on the employee's row for anyone covered with them. Or upload a CSV and we fill the table for you.
Address: every employee's full home address is asked for. A dependant defaults to "Same as employee"; untick it to enter a different address for that dependant.
Pay figure needed: These plans pay a benefit based on earnings, so we need a pay figure to quote them.
CSV or Excel format: columns are Emp Seq #, EE #, Last name, First name, Relationship, Date of birth, Gender, Street, City, State, ZIP, Coverage tier, Hire date, Employee status, Position, Pay type, Salary or rate, SSN. Relationship is Employee, Spouse, Child or Domestic partner; a spouse or child row belongs to the employee row above it. Tier accepts EE, EE+Spouse, EE+Child(ren), Family, or Waiving. Hire date, Employee status, Position, Pay type and Salary or rate apply to employee rows only. Salary or rate is required on an employee row when Accident, Hospital indemnity, Short term disability or Long term disability is requested. The older eight column template (with Tobacco and Dependents) still imports. SSN is optional: it is masked on screen, saved only into the file you download, and never sent anywhere by this page.
Please add at least one employee (or upload a census) to continue.
Contact & review
Last step: how should we reach you, and a quick look at everything before you send.
Your contact info
Review & finish
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Your information is not stored on this page, it stays in your browser until you download or email it. Because email can't attach files automatically, please attach the CSV you downloaded when your email opens.
Please add your name and a valid email so we can send your quote.