Benefits Logic

Company Name*

Number of full time employees:*

Do they currently have a group plan?*

Are they part of any association or membership? Please provide details.

Company Contact Name*

First Last

Email Address*

Do we have permission to email them?*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Interest level of client*

Any comments or details to share?

Please select G&T representative:*

G & T