Request Proposal

In order to obtain a preliminary quotation for your Medical, Dental, Long Term Disability, Short Term Disability or Group Life insurance, all information below is required in order to process a quote.

We do require all information to be provided in order to develop the proposal.

Once we have received your information, we will contact you for any additional information and develop the requests for proposals.

If you would prefer not to provide this information over the web, please contact us at
508-385-5135 or Benefits@EBSForan.com, Attention Marketing.

Please note that coverage cannot be purchased or bound over this web site. Once the initial information is received we will schedule an appointment for you to review our proposal and discuss any outstanding issues that may arise.

We thank for you for your interest in the EBS Foran Group of Companies and one of our specialists will contact you shortly.
   Contact Information
First Name:*
Last Name:*
Title:*
Phone/Ext:*
Fax:*
Email:*
   Company Information
Company Name:*
Mailing Address:*
Street Address:*
City:*
State:*
Zip:*
Company Type*
Number of Benefit Employees:*
Business Type:
SIC Code:
Number of Locations:
Number of Unions:
Out of State Employees:*
Section 125 Plan:*
   MEDICAL Benefits Plan-ONE
Carrier:
Anniversary:   Click for Calendar
Employer % Contribution:
                  
   MEDICAL Benefits Plan-TWO
Carrier: Anniversary:   Click for Calendar
Employer % Contribution:
                  
   MEDICAL Benefits Plan-THREE
Carrier:
Anniversary:   Click for Calendar
Employer % Contribution:
                  
 Medical Last Rate Increase:
   DENTAL Benefits Plan
Carrier:
Anniversary:   Click for Calendar
Employer % Contribution:
                  
   LTD Plan
Carrier:
Anniversary:   Click for Calendar
Employer % Contribution:
                  
   STD Plan
Carrier:
Anniversary:   Click for Calendar
Employer % Contribution:
                  
   Life Insurance Plan
Carrier:
Anniversary:   Click for Calendar
Employer % Contribution:
                  
   Additional Information
 Definition of ELIGIBLE Employee:*
Probationary Period Length: (month)
Any Carrier Benefits Changes:*
Are RETIREES Covered:
How Many on COBRA:*
Any Preference on Choosing Carrier
   Census Information *
  In order to process the requested quote, employee information is required.

Please download and fill out the below PDF and fax to our office.

  Download Census Form



   I have downloaded the PDF Census Form
Preferred Response:*
Urgency:*
Reached Website Through:
 
 
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EBS FORAN GROUP
8 Taunton Ave • Dennis, MA • 02638
Tel. 508.385.5135 • Fax. 508.385.5816



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