Business Name:

Location Address:

City, State, Zip

Telephone:

Email Address:

Years in Business:

General Information

Current Group Health Insurance Carrier

Current Insurance Carrier

(not agent/broker):

Number of Plan Particpants:

Total Number of Employees:

Group Life:

Group Disability:

**Information received from this quote request form sent to A.L.S. Advisors, Inc. will be for

this request you acknowledge that this is neither an offer to insure nor a guarantee of

Insurance. No coverage is bound or implied by submitting this information.

Fed. ID #:

Contact Name:

Description of Operations:

Other Group Benefits

HMO:

PPO:

PT

We are also interested in quotes on the following group benefits:

Executive Benefits:

Voluntary Products:

Group Dental:

Please verify that the contact information above is correct as there may be

additional information required to provide an accurate, bindable quote.

All quotes are subject to receipt of loss history and underwriter approval.

Questions or Comments:

our use only and will not be sold or distributed to any other parties. By submitting

FT

Name of Plan (if known):

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