Group Insurance Quote

If you are a decision maker (business owner, human resources director, etc.) for your company and are looking for an insurance policy for you and your employees, simply fill out the form below and a representative from Richard A. Feare & Associates, LTD. will respond to you within one business day.

Group Insurance Quote Form

What types of Group Health Insurance do you need?*
Medical/Healthcare	Prescription Plans
Dental Insurance	Vision Insurance
Disability	Other Services Not Listed
Life Insurance
What types of plans are you interested in?
Discount Plans / GAP
HMO
POS
PPO
Need Advice
Other Plan Not Listed
Is this a renewal of an existing insurance plan?*
Yes	No
If this is a renewal, what is the renewal date?
Will your company be contributing to the premium?*
Yes	No
Are the corporate headquarters located in your state?*
Yes	No
What is your industry?*
How many employees do you expect to enroll in the plan?*
Under 10 Employees10 to 50 Employees51 to 100 EmployeesOver 100 Employees
Describe Your Project*
Please provide any additional information that will help our Group Health Insurance providers supply an accurate quote.

Contact Information
This information is required so we can follow up with you. If you provide inaccurate or incomplete information, you may not receive a quote. We will not sell your information to another 3rd party and Richard A. Feare & Associates, LTD. will not use it for solicitation. Please see our Privacy Statement for more details on our privacy policies.
Company Name*		Contact Name*
Address*
City*
Country* United StatesCanada State/Province* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code*
Web Site
Email*
You will not receive your quote if the email address is invalid. We will only use your e-mail address in order to contact you.
Work Phone*
You will not receive your quote if the phone number is invalid. We will only use your phone number in order to contact you.
	Ext.
Mobile Phone
(eg. xxx-xxx-xxxx)
How did you hear about us?
GoogleYahooMSNOther Search EngineDirect MailBusiness CardReferral
To complete the form, please answer the math problem below:
* Indicates a required field.