APLAZ Group Inc

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Contact Name *

Title

Company Name *

Address

Email Address *

Phone (AM) *

Phone (PM) *

Fax

Business Description * (please describe the nature of your business):

Have you been in business for more than a year? *

Yes No

What Percentage will the business contribute towards a benefit plan? *

What is the current Benefits Provider?

Please mark off all the plans that you would like to get a quote for.

  PPO
  HMO
  Dental
  Life Insurance
  Section 125
  Workers’ Compensation

Comments or Questions:

Are you a robot? *

“Disclaimer” I understand that this form, merely informs Aplaz of a proposal request and is not a Policy of Insurance, Application or Offer to Insure on behalf of any Insurance Company, Agency or Agent. Individual companies reserve the right to accept, reject or modify a proposal after investigation and review.

Benefits Quote