Business Name:
Contact Name:
Mailing Address:
Phone:
Fax:
Email Address:
Current Carrier:
Renewal Date:
Employer Contribution:
How Long with Current Carrier:
Who was the Prior Carrier:
Reason Out to Bid:
Known Health Conditions:
   (diagnosis/prognosis on claims over $10,000)
    
CURRENT RATES
Employee Only:
Employee/Spouse:
Employee/Child:
Full Family:
RENEWAL RATES
Employee Only:
Employee/Spouse:
Employee/Child:
Full Family:
If age/sex rated, please include the rate table.  Please send the information to:

   KANSAS/MISSOURI
   Email:  tsawyer@sunflowerinsurance.com
   Fax:     (785) 825-5098

   COLORADO
   Email:  cmedina@sunflowerinsurance.com
   Fax #:  (719) 275-8870
You must also complete the Census Form also found on the previous page.
Comments:
Date:
 

 



 
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