Group Insurance Quote

Use This Form to Request Quotes On Multiple Group Insurance Plans

Part I of II

Please Note: If your company insures more than 10 employees, please fill out only the contact information and the plan information in Part II, a service representative will contact you to obtain the additional information needed to quote your group.

Part1: Contact Information: All Fields with a (* ) are required

Company Name

Company Description

Contact Name:*

Email Address*

Office Phone:*

( ) -

Office Fax::

( ) -

Best Time to Call

Company Address:*

Suite Number

City

State

Zip

Association Status:*:

Current Member

Prospective Member

Deliver my quote by*:

E-mail	Fax
Regular Mail	Call with information

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WORLDWIDE INSURANCE SERVICES, INC.
All Rights Reserved © 2002-2010
25775 N. Hillview Ct. Suite B
Mundelein, IL 60060
Phone: 800-955-0418 Fax 866-967-6310
Alan A Leafman, Agent state of domicile and
principal place of business AZ -CA lic# OB98320