Group Employee Benefits

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Name Required
First Name Required
Last Name Required
Street Required
City Required
State Required
ZIP / Postal Code Required
Primary Phone Number Required
E-Mail Address Required
Total Number of Employees? Required
Renewal Month Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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With offices located in:
DuBois - Corporate Office
State College Office
Wilkes Barre Office
Williamsport Office
VA Beach, VA
Ph: 800.503.7750
Fx: 800.920.7992