Proposal Form:
Company Name:
Address:
City,State Zip Code:
Contact Name:
Phone Number:
Fax Number:
Email Address:
Current Insurance Carrier:
Renewal Date:
Current Insurance Carrier:
 Renewal Date:
Number of eligible employees (working
min. 20hrs. per/wk earning min. wage):
Number of Employees Participating in Plan:
YES
NO
Do any of the participating employee's live outside  N.Y. State?
Of the participating employee's, indicate the number of each to be insured:
Employee &
Spouse:
Singles:
 Employee &
Child(ren):
Family:
Comments:
Additional Info.
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