Welcome to The American Worker

Date		( * = required field)

Broker Information
Name *
Address (line 1)		Phone Number *
(address line 2)		E-Mail address

Group/Case Information
Entity Name*
Address (line 1)		Number of Locations
(address line 2)		Nature of Business
Group Contact		Decision Maker
Title		Title
E-Mail Address		Phone Number
Eligible vs. Total Employees		Full-Time Part-Time 1099
How are Eligible Employees Determined
Average Eligible Income		Contribution % or $
Waiting Period for Eligibility	30 Days 60 Days 90 Days Other
Other Coverage Currently in Place		If Yes, what type
Target Pricing
Voluntary, Explain Participant Requirements
Requested Coverage *	Limited Medical Dental Vision Short Term Disability
	Major Medical Long Term Disability Life Insurance
	Critical Illness Preferred Catastrophic (High Deductible)
Other
Open Enrollment Dates		Coverage Effective Date
Comments