Please complete this form for each employee that is to be insured. Click on submit for each employee. If you do not want to fill out this form through email you can fax the information to 815 234 3043. If you have any questions you can call us at 800 556 8407.

*Coverage Information use the following abreviations:
Employee only = EE
Employee & Spouse = ES
Employee & Child = EC
Employee & Children = EC+
Employee & Family = EF