Palffy Insurance Group

Group Insurance Quote Request

Group Insurance Quote Form
*Required Field

Business Name*

Business Phone Number*

Business Zip Code*

Number of Employees*

Contact's Name*

Contact's Direct Phone Number*

Contact's Email Address*

Do you currently offer any types of group policies?

Select all the types of policies that you want quoted for your group:*

Additional Comments:

After you submit this quote request, we'll send you a census form along with general information on the types of plans that you selected.

We'll be able to run quotes as soon as we receive the census form back from you.

On the census form, you'll supply us with the ages and genders of each employee and their dependents who will be covered. For certain quotes, we may also ask for your employees' occupations.

You won't be giving out any personal information about specific employees. Although we ask for the age and gender of each person, we don't ask for names, birthdates, etc.

A sales agent may call you as a result of submitting this form. We may need to clarify some information while completing your quote request. We may call you to discuss your options after you receive your quote.

The information you provide will only be used to satisfy your quote request. Certain information will be shared with insurance companies for quoting purposes only. No insurance company and no other insurance agency will market to you as a result of submitting this form. We do not share your information with outside organizations for marketing purposes.