Request for Proposal

First Name *

Last Name *

Company Name *

Phone Number *

Address *

Address Line 1

City

State / Province / Region

Zip / Postal Code

Email *

Website / URL

Would this be new plan or used to replace an existing plan? *

If this is an existing plan, who is the current plan provider?

How many employees are expected to participate in this plan? *

What type of plan(s) are you interested in/do you currently have? *

Proposed Effective Date: *

Business Entity Type *

If this is an existing plan, are there any problems with the current plan?

If yes, please explain:

Any additional information that would be helpful?

How did you hear about Midwest Group Benefits?

Security *

Website