Group Health and/or Disability Quote Compass Insurance Group Health and/or Disability Submission. If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Group Name Contact First Name * Contact Last Name * Address 1 Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Email * Phone * Total # Employees on Payroll Total # of COBRA Continuants Total # Part Time/Seasonal Employees Total # Employees in Waiting Period Total # of Eligible Employees on Payroll Effective Date Do the owners receive a W-2 form from the business? YesNo Is the group a member of a Controlled Group of Corporation or of a Common Ownership as referenced in Section 414 of the Internal Revenue Code of 1986 (U.S.C. 414(b), (c), (m), or (o))? U.S.C. 414(b)U.S.C. 414(c)U.S.C. 414(m)U.S.C. 414(o) Please Check Off The Types Of Insurance Your Interested In: General LiabilityWorker’s CompCommercial AutoGroup BenefitsPayroll SolutionsGroup Health PlansIndividual Health InsuranceTime Tracking SystemsPayroll ServicesPEO/ Employee LeasingGroup BenefitsDental InsuranceVision InsuranceDisability InsuranceSupplementalsRetirement Options/InvestmentsLife InsuranceHealth InsuranceDisability Insurance What is three plus four? *
