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New South Benefits Group

Group Quote

Quote Request Form – Small Groups 2-50

* = Required Fields

Company Name: *

Contact Person: *

Number of Locations: *

Street Address: *

Street Address 2:

City: * State: * Zip: *

Phone: * Fax: E-mail: *

Industry Type: * Total # Enrolling / Waiving: *

Employer Contribution %: Participation %:

# Large Medical claims past 3 years: Renewal Date:

Health Dental Vision Life Disability (Check all that apply)

Current Carrier:# Years:

Current Plan:

Current Premium: Renewal Premium:

Proposed Plan: Proposed Effective Date:

Please provide the following documentation via fax (770) 573-9752 or email to info@newsouthbenefitsgroup.com.

Census of Full Time Employees * – Click here to download NSBG sample census

Current Plan Summary (If applicable) Current group insurance bill (if applicable)

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