A.R.M. of NY ~ Employee Benefits Services

Please complete and submit the following quote form and one of our Account Managers will review your information and contact you to prepare an insurance program analysis and proposal.

In the event you would like to schedule a meeting, please indicate a date and time that is convenient for you in the comments section of this form and an Account Manager will arrange to meet with you.

If you would like to speak with one of A.R.M.'s Insurance Specialists immediately, call 888.276.6369.

Group Benefits Application

Applicant Information
Company Name
Address
City	State Zip
Contact Name
Contact Phone Number
Contact Fax Number
Contact Email Address
Nature of Business/Sic Code
What lines of coverage do you want quoted?
Number of Employees
Comments

Current Coverage
Do you currently have coverage?	Yes No
Current Plan Type
Current Deductible
Current Premium