Health and Welfare Insurance Application

First Name*
Last Name*
Company*
Phone*
Email*
Additional Information

In order to complete the underwriting process, the following items are needed for review. Once these are completed, a proposal can be generated. You can save the form and continue later if you don’t have all of the requested documents at the moment.
Company URL*
State of Incorporation*
Current Medical Provider (if applicable)
Medical Renewal Date (if applicable)
Upload the Following Documents:*
- Employee Census – Please download, fill out, and upload the Employee Census.
- COBRA Census – Please download, fill out, and upload the COBRA Census.
- Special Risk Questionnaire – Please download, fill out, and upload the Special Risk Questionnaire.
- Automated Risk Assessment – Please download, fill out, and upload the Automated Risk Assessment.
- Current plan and a current invoice.
Drop files here or

Max. file size: 128 MB.
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later