Get a Quote

Please complete the following form to request a quote for an insurance benefit plan. Upon receipt of this form, MDSIS will contact you within 48 hours to discuss your quote. There is no cost, enrollment, or obligation when obtaining a quote. All information received by MDSIS is strictly confidential.

Please Complete Company Information

Company Name


Contact Person


Business Address


City


State


Zip Code


Email Address


Business Telephone No.


 Fax No.
Number of Eligibles to Enroll


Desired Effective Date
Currently Offering Insurance?
Yes
No

If Yes, what Plan?


Coverage Provided Through:
Complete for all Eligible Employees.

Note: Salary and Position information is required ONLY when requesting Short-Term Disability, Long-Term Disability, or Life Insurance.
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):
First Name:

Last Name:

Home Zipcode:
 Gender:
M
F

Smoker?
Yes
No 		Type of Plan:
Individual
Family
Waiving Coverage

If Waiving, State Reason:

 Date of
Birth:

Salary
(see note):

 Weekly Work
Hours:

Position
(see note):


Note: Salary and Position information is required ONLY when requesting Short-Term Disability, Long-Term Disability, or Life Insurance.