Complete  and fax the Small Group Quote Request Form  to 301-881-3782 or submit your request using the online form below.
GROUP INFORMATION BROKER INFORMATION   Company Name: Broker Name:   Full Address: Broker Agency:   Number Of Employees: Phone:   Industry Type: Fax:   Current Coverage: Email Address:   HMO  POS  PPO     Desired Effective Date: *Proposals generated in-house are typically forwarded within 24 hours of receipt.   Desired Plan: Comments: (max 150 characters)   HMO  POS  PPO Characters Left     Deductible:   MEDICAL DENTAL OTHER BENEFITS   Aetna Anthem BCBS CareFirst BCBS Kaiser Permanente United HealthCare   AIG Aetna CareFirst Denex DentaQuest Lincoln Financial CareFirst BCBS Principal   Vision STD LTD Life   Flat: X Salary: Class:     GENDER (M/F) Date of Birth (MM/DD/YR) Dependent Status COBRA?(Y/N) LIFE AMOUNT OR SALARY       EE SPOUSE Child(ren)     1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24