Request for Proposal Order Number Proposal Requested By: First Name * Last Name * Company Name Phone Number * Address 1 Address 2 City Zipcode State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana IAIowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Email Address * Website Would this be new plan or used to replace an existing plan? New Existing Plan How many employees are expected to participate in this plan? Select One 5-10 10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-75 75-100 100-125 125-150 150-200 200+ What type of plan(s) are you interested in/do you currently have? Flexible Spending Account Premium Only Plan HRA HSA 401(k) / Retirement Plan COBRA Payroll Services Proposed Effective Date: If this is an existing plan, who is the current plan provider? Business Entity Type Select One C-Corporation S-Corporation Sole Proprietorship Limited Liability Company Partnership Non-For-Profit If this is an existing plan, are there any problems with the current plan? Yes No If yes, please explain: * Any additional information that would be helpful? * How did you hear about Midwest Group Benefits? Referred by a current MGB Client Internet Search Newsletter Newspaper Ad Radio Ad Other
