Group Insurance Quote

Use This Form to Request Quotes On Multiple Group Insurance Plans

Part I of II
Please Note: If your company insures more than 10 employees, please fill out only the contact information and the plan information in Part II, a service representative will contact you to obtain the additional information needed to quote your group.
Part1: Contact Information: All Fields with a (* ) are required
Company Name
Company Description
Contact Name:*
Email Address*
Office Phone:*	( ) -
Office Fax::	( ) -
Best Time to Call
Company Address:*
Suite Number
City
State
Zip

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WORLDWIDE INSURANCE SERVICES, INC. All Rights Reserved © 2005-2007
237 Melvin Drive
Northbrook, IL 60062
Phone: 800-955-0418 Fax 847-559-9499
Alan A Leafman, Agent state of domicile and principal place of business IL -CA lic# OB98320