Are you an Individual Looking for Medical Coverage Options?

 

Click the Links below to learn more about your options & apply for coverage

Quote Requests

Please fill out the information listed below to receive a quote of benefit options as well as our recommendations

 

Please note we may need further information & a release of information to provide you with a comprehensive presentation

Employer Name

City/Zip

County

Nature of Business

Effective Date

Please mark which benefits you would like us to quote

Medical

Dental

Vision

Life

Disability

Please list your Current Carriers

 

Please click below to fill out employee census information

 

This census can be e-mailed or faxed back to us

E-mail: quote@custombenefitservice.com

Fax: (616) 301-3061

 

Contact Name

Individuals

Group Coverage

Employer Contribution

Dental

Vision

Life

Disability

%

%

%

%

Other

616.301.3060

Custom Benefit Services

Phone: 616.301.3060

Fax: 616.301.3061

Email: Support@custombenefitservice.com

Location

3425 Lake Eastbrook Blvd. SE

Grand Rapids, MI 49546