Request a Quote Form



If you prefer you can email your RFP to: quotes@northwestmarketingresources.com
Please enter your email address



Agent Name

Agent Phone

Agent Fax

Agent Mailing Address



Group Name

Group Address

Requested Benefits
	Dental Vision Life Disability STD LTD HSA Premium Only Plan Health Reimbursement Arrangement Flexible Spending Account
Is this Employr Paid or Voluntary Coverage
	Employer Paid Voluntary
If employer paid what % do they pay for EE and Dep?

Does the group have current coverage for a minimum of 12 Months?
	Yes No
Please describle the current benefits/or if no current coverage, what benefits do you want quoted?

For Dental and Vision enter the census information below.
EE Only

EE + Sp

EE + Ch

EE + Fam

For Life, STD and LTD we need a coplete census with Salaries, occupations etc. You can email it to us to quotes@northwestmarketingresources.com.



Current Plan Details
Current Carrier

Renewal Date

Please enter the group's current and renewal rates.