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Proposal Request

IF YOU ARE A BROKER, PLEASE COMPLETE THE FORM BEGINNING HERE.
Broker First and Last Name:
Email Address:
Brokerage Firm:

SELF-REFERRED EMPLOYER INFORMATION:
Contact First and Last Name:
Contact Address:
Email Address:
Proposal is for (Company Name):
Company Phone:
Number of Benefit Eligible Employees:
Plan Start Date:
If more than 1, please list Locations:
Our turn-around for proposals is 2-3 business days, is this acceptable?
Our practice is to send information via email. If you'd prefer to have information mailed to you, please make note of it in the box below. Remember to include your complete mailing address.
Special Notes or Instructions:
Is this company currently a client of Benefit Strategies?
Area(s) of Interest:
COBRA
Flexible Spending Account (FSA)
Health and Welfare Trusts
Health Reimbursement Arrangement (HRA)
Should you have an immediate, time sensitive need to receive information, please Contact Us.

 
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