Palm Beach Insurance Group, Inc. - Peace Of Mind. Palm Beach Style.

EMPLOYEE BENEFITS INFORMATION REQUEST

Please note that the completion of the following REQUEST FOR INFORMATION DOES NOT constitute proof of insurance. The only way coverage can be bound is when an agent of Palm Beach Insurance Group has issued the binder or policy and then notified you that it has been issued. IF YOU DO NOT AGREE WITH THIS DISCLAIMER, DO NOT CONTINUE!

By submitting this Request for Information Form, you confirm that you have read and agree to the above disclaimer.


Company or Name:*		Contact:
Address:		City:
State:		Zip:
Phone:		Alternate Phone:
Fax:		Email:*
How would you like to be contacted?:*

What coverages would you like to obtain information about?:
Group Benefits

	All types of health Insurance, i.e., HMO, POS, EPO, PPO
	Self Funded plans for Health & Dental, incl. min. premium and ASO.
	Dental - HMO, PPO & Indemnity
	Life
	Short & Long Term Disability
	Voluntary benefits, i.e., life, STD, LTD, Dental, Vision, LTC, Accident, Cancer
	Long Term care
	International Health plans
	Section 125/Flexible Savings Accounts/Medical Savings Accounts
	Employee Pension & 401-K Plans
	Employee Assistance Programs
	Buy/Sell Funding Agreements
	Key Executive Plans
	Access to legislative updates/Human Resources Center
	Compliance guidelines for COBRA, HIPAA, FMLA, Section 125
	Customized employee communication materials

Individual Benefits

	Life Insurance - All types available
	Disability Income insurance
	Long Term Care coverage
	Annuities
	Health Insurance
	Short Term Medical plans
	Foreign Nationals Medical plans

Click Here to Clear This Form	Click Here to Email This Form to Us!

If you do not hear from us in a reasonable amount of time, it means we did NOT receive this request for a quote, so please call our office at (561) 624-0361.
Thank you for allowing us the opportunity to serve you!

To discuss your home & valuables coverage needs, please contact Mark Saccal at (561) 624-0361 or email us at info@palmbeachinsgroup.com

Need Help?

Call 561.624.0361,
email us at: info@
palmbeachinsgroup.com,
or visit us at:
13700 U.S. Highway One,
Suite 102
Juno Beach, FL 33408

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