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Broker Information

Agent:  
Agency:  
Street Address:  
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Agency Website:  
Are You Currently Licensed With the American Worker?  
Are Other Brokers Involved?  
If So, Whom?  

Employer/Group Information

Employer/Group Name:  
Street Address:  
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Case Demographics

Total Number of Employees:  
Number of Eligible Employees:  
Which Employees are Eligible?  
Will The Employer/Group Contribute to Cost?  
If So, How Much?  
Is Other Coverage Currently In Place?  
If so, Please Provide the Carrier and Type of Coverage:  
What Type of Coverage is Being Requested?  



Is there a Waiting Period for Eligibility?  
If So, How Long?  
What Is the Target Employee Cost For Coverage?  
What is the Preferred Enrollment Communication Method?  
Proposed Effective Date:  
Open Enrollment Start Date:  
Open Enrollment End Date:  
General Comments Requests?  

 
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