GSI Quote / Executive DI - Brookfield Partners

To complete an Excel Version for RFP, you can download our GSI Quote Request Form

Company Information:
Company Name:*
Date by Which Offer is Needed:*
MM slash DD slash YYYY
Effective Date of Coverage:*
MM slash DD slash YYYY
Company Location:*
City State

Enter the Main Office Location.
Other Office Locations:
City State
How long has this business been in operation:*
How many years?
Nature of Business:*
Type of Entity:*
- C-Corp
- S-Corp
- Partnership
- LLC
- LLP
- Sole Proprietorship
Total Number of Employees:*
Number to be Considered for Offer:*
Occupations:
Nature of Employee Group to be Considered.
Premium Payor:
- Employer
- Employee
- Split ER/EE
Census:
Name Gender DOB (mm/dd/yy) Smoker (Yes/No) Resident State Position Salary Bonus
Advisor Information:
Advisor Name:*
First Last
Agent/Advisor E-Mail:*
Agent/Advisor Phone:*
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Name	Gender	DOB (mm/dd/yy)	Smoker (Yes/No)	Resident State	Position	Salary	Bonus

City	State

Company Information: