Employer Group Quote Form

Please complete the pre-quote questionnaire below to help us identify your company's needs. A licensed Frett Barrington team member will contact you within one business day to discuss your group insurance request.

We can help your firm implement a full range of benefit programs, including health, dental, life/AD&D, voluntary life/AD&D, disability, voluntary disability, flexible spending accounts, health reimbursement accounts, wellness programs, and P.O.P plans. We also offer consulting-only services.

If you would like to speak with someone immediately, please call Account Executive Patty Frett at (262) 696-5010.

Required fields are in bold and marked with a *.

First Name*
 Last Name*
E-Mail Address*
 
Phone Number*
- - 		Fax Number
- -
Company Name*
 
Company Street Address Line 1
 Company Street Address Line 2
Company City
 Company State
 Company ZIP Code
Which Group Insurance Lines Are You Interested In? (Check All That Apply)
Dental
Flexible Spending Accounts
Life/AD&D
Long Term Disability
Medical
Premium Only Plan
Short Term Disability
Vision
Requested Effective Date (MM/DD/YYYY)
/ /
Current Insurer(s) (Enter "None" If Not Applicable)
Total Number of Employees
Industry Description
SIC Code (if Not Known, Enter "None")
Comments