Proposal Request
  Please complete the following form to the best of your ability. The information you provide will assist us in determining what type of program would be best for you and your employees.
Proposal Requested By:
First Name:
Last Name:
Company Name:
Phone Number :
Address1:
Address2:
City:
State:

Quick Links
  Flex Spending Claim Form
  Flex Benefits
  Premium-Only Plan
  Flexible Spending Account
  Print HRA Claim Form
  HRA Plan
  Log on to My Flex Online
  Check HSA
  Eligible Health Reimbursement Expenses
  Flex Change in Family Status & Employee Termination Form
  Estimate Your Dependent Care Expenses
  Eligible Over the Counter Drugs
  Flexible Spending Account Savings Calculator
  Request A Proposal
  FAQ
Zip Code:
E-mail Address:
Website:
Would this be new plan or used to replace an existing plan? New   Existing Plan
How many employees are expected to participate in this plan?
What type of plan(s) are you interested in/do you currently have?
(check all that apply)
Flexible Spending Account
Premium Only Plan
HRA
HSA
Proposed Effective Date:
Business Entity Type:
If this is an existing plan, who is the current plan provider?
If this is an existing plan, are there any problems with the current plan? Yes   No
If yes, please explain:
Any additional information that would be helpful?
How did you hear about Midwest Group Benefits?
Referred by a current MGB Client
Internet Search
Newsletter
Newspaper Ad
Radio Ad
Other