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:
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?
Are you currently Fully-Insured or Self-insured? Fully-Insured   Self-insured
What type of plan(s) are you interested in/do you currently have?
(check all that apply)
Group Health Life
Individual Health Vision
Dental Disability
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