Agent:
Email:
Company Name:
Contact:
Address:
Phone:
Fax:
Total # Of Employees On Tax Documentation:
Years In Business:
Current carrier:
Type of Coverage Desired:	Select PPO HMO Dual Option
Employee Name Gender Date of Birth Spouse Age Number of Children Male Female
In order to provide you with a competitive quote... We must have an accurate company census. Simply Submit the above form. You will receive a response within five business days. Additional Information:

When looking for health insurance coverage for your employees,1St Miami Associates is your one-stop shop. We offer a wide array of health plans from many fine companies so we can tailor your benefits to your company’s specific needs. Companies from 4 to 50 employees can now offer health benefits that only large companies could offer before. Let us provide you with a personalized proposal that will set your firm apart from the rest.