Group Health Rate Quote Request Form

This is a request for a quote, not a policy application. Submitting this form does not obligate you to purchase any products. Please complete this form as accurately as possible. Insurance rates are subject to change.

Prefer to speak with us? We are here to help. Call us at: 952-465-0064.

Required *
Contact Name *
Company Name *
Address *
City *
State *
Zip *
E-mail *
Phone *

General Information

Total number of Employees*
Approximate Number of Employees participating*
Employer contribution toward Employee Cost*
If Other:
Type of Entity:*
Current Health Care Carrier (If Applicable)
Renewal Date (If Applicable)
Additional Comments