Nichols Insurance

Business Submission Form
* denotes required fields to be fully completed

Company Name *

Contact Name *

Your Title

Type of Business

Address

City *

State *

Zip *

Phone *

Fax

E-mail *

Desired Coverage Effective Date *

Number of Employees *

Current Insurance Information:

Existing Carrier *

Type of Coverage
Desired *

Health Insurance
Dental
Life

Disability
PEO (Employee Leasing)

What is Most Important
to You? *

Better Service
Lower Premiums
Lower Deductibles/Co-pays
No Referrals

Prescription Co-pays
Bigger Choice of Physicians
Multiple Plan Choices