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[PART ONE OF TWO]

REFERRAL INFORMATION
Were you referred by a Netpay sales person?
If so, who?
Are you a current Netpay client
If so, what is your client number?
GROUP INFORMATION
Company Name Contact Name
Address Email
Phone  
Nature of Business SIC Code
Legal Structure  
Current Medical Carrier Plan Type
Current Monthly Premium  
Does Group Have Dental Plan?
Dental carrier
Requested Effective Date mm/dd/yyyy
# Eligible Employees . # Part-Time Employees
Out of State Employees?
 
% of Costs to be Paid by Employer Employee costs Dependent costs
     
LIFE INSURANCE INFORMATION Security Question

Are you interested in including life insurance?

 

 

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