Request A Quote

Thank you for your interest in Ternian Insurance Group. If you would like to receive a group quote on Ternian’s products and services, please fill out and submit this online Request For Quote Form.

Company Information:

Business Name *


Type of Group *

Contact Name and Title


Company Address


City


State


Zip


Phone


Email *


Website


Situs State


SIC Code


EIN Number


Program Information:

Number of Eligible Employees


Proposed Effective Date

Select a date from the calendar.

Eligibility Statement (who is eligible for this coverage)


100% Employee Paid

If No, Employer Contribution Amount


Census available for eligible employees?

Current mini-med and/or major-med plan in place

Carrier


Agent Information:

Name


Agency


Agent Phone


Agent Email


Broker of record

Agent Address


Attachments