Consumer Directed Employee Benefit Solutions
BBB Accredited Business
  
Call us : 901-219-8835
Email : marlin@cdbsagency.com
The Right coverage at the right price makes all the difference
 
   
 
   
 

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Legal Name of Business:
Contact Name:
Address:
City:
State:     Zip:
Business Phone:   Fax:
Best Time To Call:   AM   PM
E-mail Address:

Type of Business
Type of Business:
No. of Full Time Employees:   No. of Part Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Health Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:   Premium Amount: $
Years Insured:
Please give a brief description of your current Group Health plan:

Benefits Desired
Major Medical
Deductible: 		Optional
Pregnancy Coverage: 		Yes
No
Dental Coverage: Yes
No		 Supplemental
Accident Coverage: 		Yes
No
Disability Insurance: Yes
No		 Group Life Insurance: Yes
No
Life Ins. Amount :
 $    

Employee Information
Please list all employees you wish to cover:
Employee Name Date of Birth Zip Code Sex Dependent Status
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
Male
Fem
If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or e-mail an additional listing.


Additional Comments or Questions

Please click the "Submit Quote" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.

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