GHP - PEO ►Professional Employer HR Outsourcing & Insurance Services
Information and Quote Request Form
Please select areas of interest below and submit to GHP - PEO
(Please use this form for both Individual or Business Related Products and Services)
Referring Broker Name Broker Phone (123-123-1234)
Referring Agency
Company Name
Contact Name
Position
# Employees: Business Description:
Address
City State Zip code
Phone Ext Fax
Email Address:
Gross Payroll Per Week Bi-Weekly Month Year
Requested Effective Date (xx/xx/Year)
Please contact me regarding my interest in the below selected products!
Individual Coverage Group Coverage
Benefits to Offer:
Health Insurance Benefits
TYPE: HMO's PPO's POS's
Traditional Major Medical Health savings accounts (hsa's)
Dental Insurance
Vision Insurance
Life Insurance
401 (k) Employee Savings Plans
Disability Income Protection
Supplemental/ voluntary Insurance (Cancer, Critical Illness, Voluntary Life, Accident)
HR AND PAYROLL ADMINISTRATION SERVICES
Customized Employee Handbooks
Workers' Compensation Insurance
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