Employers Benefit Group

We've got you covered with medical, dental, life, disability, vision and long term care. We also offer Medicare, short term medical, travel accident, and international medical products, Health Savings Accounts and retirement services (planning, rollovers, IRAs, etc.).

We have access to hundreds of insurance companies to meet the individual needs of our clients. Policies can differ widely in coverage and cost; we will "shop the market" to find the best insurance plan to fit your situation.

If you are interested in a no-obligation quote, please provide us with the following information:
("*" are required fields.)

Personal Information

First Name:*

Last Name:*

Address:*

City:*

State:*

Zipcode:*

Phone: (xxx-xxx-xxxx)

Email Address:*

Preferred method of contact:* Phone Email

Applicant/Family Member Information

(Complete Only For Family Members Applying For Coverage)

	Gender	Height/Weight	Birthdate

Applicant	Male	(ex. 5'8")
Applicant	Female	lbs.

Spouse	Male	(ex. 5'8")
Spouse	Female	lbs.

Child 1	Male	(ex. 5'8")
Child 1	Female	lbs.

Child 2	Male	(ex. 5'8")
Child 2	Female	lbs.

Child 3	Male	(ex. 5'8")
Child 3	Female	lbs.

Child 4	Male	(ex. 5'8")
Child 4	Female	lbs.

Does Any Person Use Tobacco?
If So, Please Explain In Detail.

Any Health Problems That Could Affect Your Premium?
If So, Please Explain In Detail.

Type of Insurance You're Interested In:

Requested Effective Date:*

If an agent referred you to Employers Benefit Group, please provide agent or agency name:

Ready to apply for coverage?
Click on the appropriate carrier below to get started!

	Anthem

	Humana One

	WPS

	Security Health Plan

	Celtic

	Assurant Health Short Term

	Assurant Health Quotes