CPS-Reliable Financial Group
Experts in Business, Estate and Personal Life Planning
A CPS Insurance Services, Inc. Affiliated Office
 
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Small Group Quote Request

The Small Group Quote Request Form is for companies and rganizations of up to 49 people.
Please make sure that you provide an accurate email and telephone number so that your CPS-Reliable CSR can contact you if additional information is needed to complete your request

Broker / Agency Information
Broker Name:
Agency Name:
Broker Address:
City:
State:
Zip Code:
Phone:
Email:
Fax:
License #:
Group Information
Group Name:
Requested Effective Date
(xx/xx/xxxx) California Groups Only
Zip:
Sic Code:
Nature of Business:
Quote Specifications (check all that apply)
Blind Quote: Yes No
Due Date: (xx/xx/xxxx)
Delivery Method: Email Fax Overnight Hold for Pick up
Type of Carveout:
RAF: Lowest Standard Highest
Census Information

Deps: EE=Employee Only  ES=Employee + Spouse  CH=+ One Child  FA=+ Family
Name
DOB
Gender
Deps
Zip
Cobra
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Additional Comments?
Please fill out all information completely and accurately.

 

 

 

 

 

 


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Web site Created: September 2002
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