Small Group Health Insurance Quote FormPlease enable JavaScript in your browser to complete this form. - Step 1 of 3Prefer to complete offline? No problem! Download Form Upload FormRequested Effective Date: *Doctor/Owner's Name(s): *Type of Business: *Company Entity (Legal) Name: *Email *Phone *Insurance Contact (if different):Preferred Method of Contact (select all that apply): *PhoneEmailTextZip Code: *NextAll Employees & Spouse/Dependents to be Covered:Please provide a census that includes Employee (or Spouse/Dependent) Name, Date of Birth, and Gender (select one):Send us your census via email (advisor@wallacesig.com), fax (214.635.1099) Download Form Upload FormEnter information1. Name:FirstLastDate of Birth:Gender:MaleFemaleCoverage for spouse or dependent?YesNoIs this person a (select one):SpouseDependent2. Name: FirstLastDate of Birth:Gender: MaleFemaleCoverage for spouse or dependent? YesNoIs this person a (select one): SpouseDependent3. Name:FirstLastDate of Birth:Gender:MaleFemaleCoverage for spouse or dependent?YesNoIs this person a (select one): SpouseDependent4. Name:FirstLastDate of Birth:Gender: MaleFemaleCoverage for spouse or dependent?YesNoIs this person a (select one): SpouseDependent5. Name: FirstLastDate of Birth: Gender:MaleFemaleCoverage for spouse or dependent? YesNoIs this person a (select one): SpouseDependent6. Name:FirstLastDate of Birth: Gender: MaleFemaleCoverage for spouse or dependent?YesNoIs this person a (select one): SpouseDependentPreviousNextHow did you hear about us?I'm interested in the following employee benefits:Group Dental InsuranceGroup Vision InsuranceGroup Life InsuranceGroup Short Term Disability InsuranceGroup Long Term Disability InsuranceVoluntary employee paid insurance (cancer, critical illness, etc.)I'm also interested in:Office Property/General LiabiltyWorker's CompensationData Breach / Cyber LiabilityEmployment Practices LiabilityProfessional Liability (Malpractice) Disability for Business OwnersTerm LifePersonal Home & AutoAdditional information for my advisor:Custom Captcha * = PreviousSubmit
