To receive a FREE, No Obligation quote for medical and/or dental insurance, simply complete this form and submit. It's that simple!

You will receive a comprehensive report comparing the premiums and benefits of the major carriers offering coverage to your size group in Washington State. The privacy of your information will be protected and your data will not be sold or used for any purpose other than to the extent needed to obtain quotes for you.

If you prefer, print this form and fax to (425) 821-3587.

If you have any questions, please call: 1-800-385-1538.

Company Name:
Contact:
Owner:
Email Address:	(required)
Street Address:
City:
State:	Zip:
Phone:
Fax:
Type of business:	(If Applicable)
Where did you hear about us? Mailing Search Engine Radio Newspaper Online Yellow Pages Yellow Pages - Hard Copy Friend Other
What type of benefits are you seeking? Medical  Dental  Maternity  Life  Disability  Retirement
Current Medical Carrier:
Deductible:
Current Dental Carrier:
Renewal Date (if known):
Employer Pays:	% of Employee premium and
	% for dependents
Comments:

Please complete for each employee:

Employee Name	Age/DOB	Sex	Smoker	Coverage Type    Spouse Age/DOB		Smoker	# of Kids
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN
		MF	YN	- Select - Employee Emp. & Spouse Emp. & Children Emp., Sp. & Children		YN