SOLUTIONS FOR SMALL BUSINESSES
REQUEST FOR QUOTE FORM
Instructions
1. Fill out group / broker info below
2. Enter census
3. Return to:
             Fax: 909.980.1084  Attn: Cris Drake
          Email: Cris@MorganAndFranz.com
4. For information or questions, contact Cris Drake at 909.980.1194
Group / Broker Info
Broker:
Broker Phone:
Broker Email:
Client Name:
Client Phone:
Client Email:
Client Zip:
Client Industry:
Renewal Date:
Proposed Effective Date:
 
Current Carrier:
Current Plan:
Current Monthly Premium:
 
Known Medical Issues:
Date Proposal Needed by:
   
Total Employees:
Total Eligible:
Census          Name                     Age/DOB                 Home Zip                    EE/ES/EC/F
1
2
3
4
5
6
7
8
9
10
11
12
13
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20
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22
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25

© 2007 Benefit Advantage
10606 Trademark Parkway North #201A
Rancho Cucamonga, CA 91730
909-980-1194 phone    •    909-980-1084 fax

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