Request a Proposal for Your Client

BASIC is very pleased to provide the proposals you need. Please use this form if you are requesting a  proposal for a third party.

Request A Proposal

The section below is to provide information on the Health Insurance Agent or HR Consultant that is requesting the proposal for their client. Important: Due to the nature and timeliness of ACA, a 30% surcharge will be added to clients who sign-up after September 30, 2016.

Your Information


Your Name: *
Referring Company Name: *
Street Address:
City:
Referring Company State: *
Postal / Zip Code: *
Phone: *
Alternate Phone:
Email: *
Will you be paying for any of BASIC's services on behalf of your client? *

Client Information

The section below is to provide information about the company/organization in which the services proposed would be presented.


First Name:
Last Name:
Company Name: *
Primary Address Street:
Primary Address City:
Primary Address State:
Zip code: *
Phone Number: *
Email Address: *
Number of employees: *
Total number of employees on health plans:
Are you a Health Insurance Agent? *

BASIC Services

Below are BASIC's Full Circle Service offering, select each service you would like a proposed. Please review each section to maximize your savings and efficiency.

HR Services:
HR Management:
HR Benefits:
How did you hear about BASIC's services?: *
Comments:
Insurance Agent's Name:

By providing your contact information, including email, you may receive promotional emails from BASIC regarding products and services, webinars, important legal and industry updates, and other pertinent information. You may at any time opt out of receiving future mailings by using the unsubscribe link provided on those mailings.

All information and material provided in our proposal are subject to copyrights owned by BASIC. Any reproduction, retransmission, republication, or other use of all or part of any document found on this site is expressly prohibited, unless prior written permission has been granted by BASIC copyright owner. All other rights reserved.