Employer Group Coverage "*" indicates required fields Your Basics:Company Name: Your Name: Business ZIP Code:* Email Address:* Phone Number:Your Details:Industry / SIC Code:Select...Agriculture, Forestry, And FishingMiningConstructionManufacturingTransportation, Communications, Electric, Gas, And Sanitary ServicesWholesale TradeRetail TradeFinance, Insurance, And Real EstateServicesPublic AdministrationOtherPlease enter the SIC Code appropriate to your business. If you are unclear of which SIC Code to use, please consult OSHA's SIC Code reference guide, available here.Effective Date:* MM slash DD slash YYYY Existing plan carrier(s)?* Aetna BCBS Cigna Humana United Healthcare Other No Current Coverage Which Products do you want to quote?:* Medical Dental Vision Life Short-Term Disability Long-Term Disability Accident/Critical Illness Other Employee Census*SelectManual EntryUpload CensusSelect Manual Entry, or UploadEmployee List:First Name:Last Name:DOB or Age:Gender (M/F):Employee ZIP: Add RemovePlease include all full-time eligible employees that may enroll any group benefit plan. Ineligible employees such as part-time workers can be excluded. Upload Census File*Accepted file types: xlsx, pdf, csv, Max. file size: 256 MB.If you do not have an employee census already prepared, please download and use our template file.PhoneThis field is for validation purposes and should be left unchanged. Δ
