Midland Insurance Group

benefits Employee Benefits Quote Fax Form

Please print this form, fill in the information, and fax it to
(320) 485-2199

Also, fax us a copy of your most recent billing and a current employee census.
If you have a coverage summary, that would also be helpful.
This will give us the information regarding your business we need to prepare a quote.

Name

 _______________________________________________________

Type of Business

 _______________________________________________________

Phone number
with area code

 _______________________________________________________

Best time to call

 _______________________________________________________


Thank You!
We will contact you soon!

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