Request a Group Proposal | Agent Service Team

Groups of up to 100 employees This form is for groups of 100 or fewer employees, plus their spouses and children. Larger groups need approval from the Agent Service Team: call 1-888-818-6070 or email the census to quote@agentserviceteam.com.

Agent of Record

First name*

Last name*

Phone*

Email*

The Group

Business name*

SIC codeoptional

Physical address*

City*

State*

ZIP*

Group Contact

Contact nameoptional

Business phoneoptional

Contact phoneoptional

Contact emailoptional

Coverage

Estimated effective date*

Size of group*

Is this group currently insured?*

Yes No

Assessment Data*

List every person to be covered, with each employee, spouse and child on their own row. In most cases your own spreadsheet format should work; look carefully at the preview to correct any data mapping issues. You can Download the AST Assessment Template HERE.

Choose a file or drag it here .xlsx, .xls or .csv — nothing is sent until you submit

No file handy?

Notes for our teamoptional

Proposal rates are valid for 30 days from the proposal date.

Every group is re-assessed 30 days before its effective date.

If the census changes by 10% or more between quoting and enrollment, we'll re-run the group's health assessment.

Request received

Agent of Record

The Group

Group Contact

Coverage

Products to Present*

Assessment Data*