Group Quote Form

Major Medical, PPO,EPO,POS,HMO,Group Dental,Disability,Vision and Life for groups of:
(1-100) employees.
Use this form to request a quote to designed meet the special needs of your company.

Part I of II
Please Note: If your company insures more than 10 employees, please fill out only the contact information and the plan information in Part II, a service representative will contact you to obtain the additional information needed to quote your group.
*Part1: Contact Information: All Fields with a ( ) are required**
Company Name
Company Description
Contact Name:*
Email Address*
Confirm Email:*
Office Phone:*	( ) -
Office Fax::	( ) -
Best Time to Call
Company Address:
Suite Number
City
State
Zip

Alan A Leafman, Agent state of domicile and principal place of business IL -CA lic# OB98320
All Rights Reserved WORLDWIDE INSURANCE SERVICES, INC. © 2005-2007
237 Melvin Drive
Northbrook, Il. 60062
Phone: 800-955-0418 Fax 847-559-9499