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Group Questionnaire

Company Information

Company Name

Address

SIC Code

Contact First Name

Contact Last Name

Contact Title

Contact Phone Number

Contact Email

Company Data

(Estimates)

Number of Owners

Number of Managers

Full Time Employees

Part Time Employees

Salaried Employees

Hourly Employees

1099 Contractors

Benefits Desired

Health Insurance

Dental / Vision Insurance

Group Disability

Group Life

Premium Saver Plan

Other

Briefly Explain

Plan Start Date

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We’ll contact this person only in case of emergency.

Business Hours:

Monday - Friday

9:00AM - 5PM CST

1334 Brittmoore Rd Ste 1000B

Houston, TX 77043

(833)223 - 8399

info@franklininsurancesolutions.com

©2022 by Franklin Insurance Solutions LLC

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