Benefit Quote Request Form
Items marked in red are required.

I would like to receive a quote
on the following benefit(s):

Health Insurance

Dental (Individual Only)

Dental (2 employees or more)

Life & Disability (2-9 Employees)

Life & Disability (20 Employees or more)
Contact Name:
Contact Title:
Company:
Address:
City:     State:
Zip/Postal Code:
Phone:
Email:
Greater Akron Chamber Member? Yes, I am a member of the Greater Akron Chamber
No, I am not a member of the Greater Akron Chamber
Number of Employees:
Do you currently have an
independent insurance agent you
already work with regarding
this/these benefit(s)? (required)
Yes     No

If yes, your Agent's full name please:

 
One Cascade Plaza, 17th Floor • Akron, OH 44308-1192 • (330) 376-5550 • (800) 621-8001 Toll Free • Fax (330) 379-3164