LA FAM | Group Benefits Intake

1. Business Information

Company Name

Contact Name

Phone Number

Best Email

Business Street Address

EIN

Main Domicile State & ZIP Code

Are all employees in the same state?

Type of Business / Industry

Who is authorized to handle billing and finances?

Full-Time Employees

Part-Time Employees

Do you expect to hire more employees in the next 6 months?

Employee Classification

Don't have an employee census? See Census Template — Make a Copy ↗

Make your own copy and fill in the employee information. Do not edit the original template.

2. Current Coverage & Timing

Is this your first time offering benefits?

When should the new plan start?

3. Benefits Goals & Budget

Why do you want to offer benefits? (Select all that apply)

Lower CostBetter CoverageEmployee RetentionOther

Employee Benefits Budget — How much is the company willing to contribute?

Per Employee / Month

Total Company / Year

Want to contribute more for managers or key employees?

Employee Salary — What is the typical annual salary for your employees? (Optional)

If pay varies widely, ask for approximate salary ranges by role or refer to the employee census.

Any known serious health conditions that may affect group quoting? (Optional)

Do not list employee names, diagnoses or medical details here. Only collect health information when required for the specific quote and through an approved secure process.

Agent Expectations & Notes

Quote Timeline Reminder

Premium quotes may take up to 30–45 days. Set expectations early and allow enough time for accurate quoting and review. Avoid promising rushed turnaround.

Agent Notes / Next Steps

Information stays in this browser unless you download or print it. No online submission or automatic storage. Collect EIN and sensitive data using an approved secure process.

1. Business Information

2. Current Coverage & Timing

Current Plan & Renewal Details

3. Benefits Goals & Budget

Agent Expectations & Notes