Request a Quote

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Please fill out the form in entirety below to submit your business’s request for quote. If preferred, you can download the physical form, complete it, and email directly to tina@yorkbuilders.com.

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"*" indicates required fields

Group Name*

Group Contact Person*

EIN*

SIC*

Group Email Address*

Group Phone Number*

Group Address*

Street Address Address Line 2 City State ZIP Code

County*

Date Business Started*

Current Insurance Information

Current Medical Carrier, Plan, and Effective Date*

Current Dental Carrier, Plan, and Effective Date*

Current Vision Carrier, Plan, and Effective Date*

Current Life / STD / LTD Carrier, Plan, and Effective Date*

Provide the Total Number of Employees for Each Category

Employees on Payroll*

Eligible Employees*

Participating Employees*

Waiving Employees*

Out of Area Employees*

Employee Information

Please use this section to complete all information for each employee. Please fill out one group of six boxes for each employee and their dependent(s).

Employees

Full Name	Date of Birth	Enrolled Status	Dependent Status	Home State and Zip Code	Actions

There are no Employees.

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Phone

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Let’s Get Started!

Current Insurance Information

Provide the Total Number of Employees for Each Category

Employee Information

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