Group Proposal Request Information

Forwarded to Breslau Insurance & Benefits - Phone/Fax (877) 538-7168

Your name:

Your employer group's name:

Address:
Street:
City:
State: Zip:

Are all employees at this location? Yes No
If no please describe in comments or call 1-877-538-7168.

Phone: - Fax: Please include area codes.

Your EMail address: required

Nature of Business / SIC if known:

Employer Contribution
To Employee Cost / Dependent Cost:

/

Current Insurance Carrier:

Current Copay, Deductible, Coinsurance:

Or fax current Benefit Summary to 1-877-538-7168

Current Rates and/or Premium:

Or fax current invoice to 1-877-538-7168, add ages for census

Renewal % Increase or Rates:

Or fax renewal letter to 1-877-538-7168

Renewal Date or Desired Effective Date:

Our Employees Are:
On Our Own Payroll
Paid By Payroll Company
Leased Employees

Any Known Existing Pregnancies?

Describe Any Known Serious Illness?

Describe Any Claims over $5,000 in Prior 2 Years?

Describe Any Recent Disabilities or Surgeries?

Employee Census: please select one of the following;

1. FAX your current health insurance invoice to 1-877-538-7168 with ages added.
- or -
1A. FAX your renewal letter and attachments to 1-877-538-7168.

2. Download and FAX Acrobat PDF CENSUS FORM to 1-877-538-7168.
Close window when done and finish submitting this group proposal request.

3. Open new window to complete and submit CENSUS INFORMATION online.

Close window when done and finish submitting this group proposal request.


4. Call Paul Breslau at (602) 692-6832 to discuss.

Comments:

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- Description:

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