Request Quote – Western Grocers Employee Benefits Trust

CLICK HERE FOR A PRINTABLE BROCHURE:
Oregon & Washington | Idaho

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Three Ways To Submit Your Request for a Quote:

Complete this form on-line
Print this form and fax it to us at (503) 968-2817
Print this form and mail it to us

Note: To provide you a quote we need a census of all participating employees and their dependents.
Minimum census information required for a quote is:
– Last Name / Initial / Employee, Spouse or Dependant? / Birthdate xx/xx/xxxx

Census Form to complete:
Share a Census of all your eligible employees for rating or a quote.
Employee Census Form | Group Life & Disability Census Form

Here is the information we need to prepare your quote:

Quote Request Form

"*" indicates required fields

Employer Information for Quote

Business Name*

Contact Name*

Email*

Phone*

Business Address*

Street Address City State ZIP Code

Participation

Tell us about the employees you wish to insure

Requirements for participation in the Plan include:
- 75% of eligible employees must participate
- Eligible employees must work a minimum of 20 hours per week
- At least 2 employees (who are not spouses) must participate

Number of Employees who are Eligible for health coverage?*

Email or Fax us a completed Census Form.

Would you like more information on any of these additional enhancements?

Dental Coverage

125 Plan (Flexible Benefits)

Health Reimbursement Accounts

Life Insurance & Short Term Disability

Check here if you are a member of the WFIA:

Yes

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Once we receive your request, a proposal will be prepared that provides rates for your group for all our benefit plans as seen on the Benefits Summary.