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Testimonials
"Within 30 minutes of calling (Nevada Benefits) I had tons of options. Thanks for saving me over $60 dollars per month."
- Chris in Reno, NV
"When Trish told me to keep what I had, I was shocked! I had called three other agents and they all tried selling me something that wouldn't have covered me. I'll keep giving you guys all my referrals. At least I can feel good about giving people your number."
- Kelly in Las Vegas, NV
"When I looked at my financial plan you guys prepared, I almost fell over. I'm way off! You got me back on track (I will max out my 401K, I promise!)."
- Roger via Email
 
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Company Name
Contact Name
Business Address
Phone Number
Fax Number
Email Address
Business Start Date
City
Nevada Zip Code
How did you hear about us?
Does the company have offices in any other state?
yes no
If yes, what states?
Nature of your business?
Does the business have a business license?
yes no

Do you file a quarterly wage and tax report for all W-2 employees?
yes no
Who is your current health insurance carrier?
Requested effective date for your new plan:
Which plans are you interested in?
HMOs PPOs All Plans
Which Options are you interested in?
Prescription Drug Card
Long-Term Disability
Dental
Group Life Insurance
Maternity
Pension Planning
Employee 1
male female
Date of Birth
Spouse's Age
No. of Children
Employee 2
male female
Date of Birth
Spouse's Age
No. of Children
Employee 3
male female
Date of Birth
Spouse's Age
No. of Children
Employee 4
male female
Date of Birth
Spouse's Age
No. of Children
Employee 5
male female
Date of Birth
Spouse's Age
No. of Children
Is any employee or dependent now pregnant?
yes no
Does any employee or dependent have any health problems or has anyone had surgery in the last 3 years?
yes no
If yes, please describe:
Is any employee or dependent taking any medications?
yes no
If so, what condition is the medication for and what is the dosage?

 
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