To obtain a group quote please fill out the following form to the best of your ability in order to receive the most accurate pricing.

NOTE: We are licensed to sell insurance & financial products in the states of Wisconsin & Illinois only.
General Business Information
Business Name
Mailing Address
City
State
Zip Code
Business Phone#
Business Fax#
Contact Name
Contact E-mail Address
Type of Business
Number of Full Time Employees
Number of Participating Employees
Group Life Insurance Coverage
Current Insurance Company
Renewal Date (DD/MM/YYYY)
Current Rate
Renewal Rate
Death Benefit
Group Health Coverage
Current Insurance Company
Renewal Date (DD/MM/YYYY)
Current Rate
Renewal Rate
Current Plan HMO       PPO       Indemnity
Deductible
Co-Pay
Co-Insurance
Lifetime Maximum Benefit
Group Dental Coverage
Current Insurance Company
Renewal Date (DD/MM/YYYY)
Current Rate
Renewal Rate
Deductible
Yearly Maxium Benefit
Group Disability Coverage
Current Insurance Company
Renewal Date (DD/MM/YYYY)
Current Plan STD      LTD
Short Term Disability (STD)
Current Rate
Renewal Rate
Elimination Period
Maximum Benefit
Maximum Benefit Period
Long Term Disability (LTD)
Current Rate
Renewal Rate
Elimination Period
Percentage Payable
Maximum Benefit
Maximum Benefit Period
Additional Comments
A complete employee census with Name, Date of Birth, Sex & Coverage Type will be required for all inquiries. Job Title and Earnings will also be required if requesting STD or LTD.
Please put any additional information or questions that pertain to your inquiry.
Image Validation:
Please enter the characters
in the image to the right.
All letters are lowercase. 		Image Validation
Characters:

Securities offered through Woodbury Financial Services, Inc., Member NASD, SIPC PO Box 64284, St Paul, MN 55164 - ph#651-738-4000

   Copyright © 2012 Glavinsured Agency, Inc.  All rights reserved.  Use of this Web site is subject                         to these Terms and Conditions of Use.  Also see our Privacy Policy.