Request A Quote

Group Name*

Contact Name*

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

For Non-Profit Entities:

Select your funding sources

State

County

City

Other

Please provide a copy of budget/financial statement to verify ongoing state/county/city funding for operations:

Max. file size: 10 MB.

Number of Employees

Number Eligible for Benefits

Number of COBRA Enrollees

Number of Retirees

Current Eligibility Definition

Desired Effective Date

Do you work with a Broker?

Yes

No

Current Plan Summaries

Drop files here or

Max. file size: 256 MB.

Current Rates

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Max. file size: 256 MB.

Group Claim Experience, if available

Drop files here or

Max. file size: 256 MB.

If Non-Profit, proof of ongoing government funding

Max. file size: 256 MB.

Please contact Rochelle Tolliver at rochelle@wcif.net or 360-292-4474 if you have any questions

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