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Company Information Your Company Name: Company start date : Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec  yr   Start coverage from : Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Do you have current medical plan? No Yes Who is your current provider / carrier ? AAA Insurance Co. AETNA AFLAC AIG AIU Insurance Allied Allstate County Mutual Allstate Indemnity Allstate Insurance American Alliance Insurance American Automobile Insurance American Benefit Planners American Casualty American Deposit Insurance American Direct Business Insurance American Empire Insurance American Family Insurance American Family Mutual American Financial American Home Assurance American Insurance American International Ins American International Pacific American International South American Manufacturers American Mayflower Insurance American Motorists Insurance American National Insurance American Premier Insurance American Protection Insurance American Republic American Savers Plan American Service Insurance American Skyline Insurance Company American Spirit Insurance American Standard Insurance - OH American Standard Insurance - WI Amica Insurance Arbella Associated Indemnity Assurant Atlanta Casualty Atlantic Indemnity Auto Club Insurance Company Blue Cross and Blue Shield Borden Hamman Cal Farm Insurance California State Automobile Association Chubb Civil Services Employees Insurance Group Clarendon American Insurance Clarendon National Insurance CNA Colonial Insurance Company Not Listed Continental Casualty Continental Divide Insurance Continental Insurance Cotton States Insurance Country Financial Countrywide Insurance Dairyland County Mutual Co of TX Dairyland Insurance Electric Insurance Erie Insurance Company Erie Insurance Exchange Erie Insurance Group Erie Insurance Property and Casualty Esurance Explorer Farm Bureau/Farm Family/Rural Farmers Insurance Farmers Insurance Exchange Farmers TX County Mutual Farmers Union Fire and Casualty Insurance Co of CT Fireman's Fund Foremost Geico Casualty Geico General Insurance Geico Indemnity GMAC Insurance Golden Rule Insurance Government Employees Insurance Great American Guaranty National Insurance Guide One Insurance Hanover Lloyd's Insurance Company Hartford Accident and Indemnity Hartford Casualty Insurance Hartford Fire Insurance Hartford Insurance Co of Illinois Hartford Insurance Co of the Southeast Hartford Omni Hartford Underwriters Insurance Health Plus of America HealthShare American Horace Mann Humana IFA Auto Insurance IGF Insurance Infinity Insurance Infinity National Insurance Infinity Select Insurance Integon John Hancock Kaiser Permanente Kemper Insurance Landmark American Insurance Leader National Insurance Leader Preferred Insurance Leader Specialty Insurance Liberty Insurance Corp Liberty Mutual Fire Insurance Liberty Mutual Insurance Liberty National Liberty Northwest Insurance Lumbermens Mutual Maryland Casualty Mass Mutual Mega/Midwest Mercury MetLife Auto and Home Metropolitan Insurance Co. Mid Century Insurance Mid-Continent Casualty Middlesex Insurance Midland National Life Mutual of New York Mutual Of Omaha National Ben Franklin Insurance National Casualty National Continental Insurance National Fire Insurance Company of Hartford National Health Insurance National Indemnity National Union Fire Insurance of LA National Union Fire Insurance of PA Nationwide General Insurance Nationwide Mutual Fire Insurance Nationwide Mutual Insurance Nationwide Property and Casualty New York Life Insurance Northwestern Mutual Life Northwestern Pacific Indemnity Omni Indemnity Omni Insurance Orion Insurance Pacific Indemnity Pacific Insurance Pafco General Insurance Patriot General Insurance Peak Property and Casualty Insurance PEMCO Insurance Progressive Progressive Auto Pro Prudential Insurance Co. RBC Liberty Insurance Reliance Insurance Reliance National Indemnity Reliance National Insurance Republic Indemnity Response Insurance SAFECO Safeway Insurance Safeway Insurance Co of AL Safeway Insurance Co of GA Safeway Insurance Co of LA Security Insurance Co of Hartford Security National Insurance Co of FL Sentinel Insurance Sentry Insurance a Mutual Company Sentry Insurance Group Shelter Insurance Co. St. Paul St. Paul Fire and Marine St. Paul Insurance Standard Fire Insurance Company State and County Mutual Fire Insurance State Farm County State Farm Fire and Cas State Farm General State Farm Indemnity State Farm Insurance Co. State Farm Lloyds Tx State Farm Mutual Auto State National Insurance Superior American Insurance Superior Guaranty Insurance Superior Insurance The Ahbe Group TICO Insurance TIG Countrywide Insurance Titan Travelers Indemnity Travelers Insurance Company Tri-State Consumer Insurance Twin City Fire Insurance UniCare United Pacific Insurance United Security United Services Automobile Association Unitrin Direct Universal Underwriters Insurance US Financial US Health Group USAA USF and G Viking County Mutual Insurance Viking Insurance Co of WI Western Mutual Windsor Insurance Woodlands Financial Group Zurich North America Policy expiration/renewal month : Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2025 2026 2027 How long have you been insured with your current insurance company? 0 1 2 3 4 5+ Describe your business (Enter the SIC number.) Any office outside US? No Yes Do you carry worker's compensation? No Yes Employee Information No Name Age Gender Zip Code Spouse Children Annual Salary Delete 1. M F Not Covered Covered 0 1 2 3 4 5+ $ Delete

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