Wells Financial Services - Group Insurance Quote Request

Company: *

Address: *

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Contact Name: *

First Last

Phone Number:

### - ### - ####

Email: *

Confirm: Email: *

Number of Full Time Employees:

Part Time Employees:

Do you currently provide a Health Insurance plan for your Employees?

Yes   No

Do you provide Life Insurance for your Employees?

Yes   No

How much Group Life Insurance does the company provide?

Does Management have additional Group Life Insurance?

Yes   No

If yes, how much additional Life Insurance?

Do you provide Short Term Disability for your Employees?

Yes   No

Do you provide Long Term Disability for your Employees?

Yes   No

How many COBRA participants are on your plan?

How many Full Time Employees are covered on your plan?

How many Full Time Employees are NOT covered on your plan?

Is any Employee or covered Spouse pregnant?

Yes   No

If yes, how many?

Are you aware of any health conditions that will effect the quoting of your Group?

Yes   No

If yes, please provide information:

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p.314.892.2456 | f.314.785.7500 | info@wellsfs.com | 4729 Brookton Way | St. Louis, Missouri, 63128