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Get a Personalized Quote

Submit the group census form below to get a quote. Easily navigate this form by selecting an item from the side menu. You can also download the form here.

Disclaimer: We will NOT provide your personal information to any third party. Privacy Policy

Tell us about your business to get started.

Select the type of coverage you're looking for: * Required

Health

Dental

Vision

Accident

Disability

Life

Are you interested in Benefit Accounts? *

Yes

No

Unsure

Are you interested in Compliance? *

Yes

No

Unsure

Do you currently offer employee benefits?

OR, upload your current renewal here

Upload supported file (Max 15MB)

Now, let us know whom we should contact with the quotes.

Contact Name

Position/Title

Contact Email Address

Contact Phone Number

Who is your LEB agent? (if applicable)

Lastly, we need a few details about your employees.

More than 50 employees? Please email us at sales@lebinsurancegroup.com or call (920) 243-4005.

How many employees will be covered under the plan?

Please fill out the following information for each employee:

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Date of Birth

Gender

Zip Code

Spouse?

Yes

No

Children?

Yes

No

Ready to Submit?

Please review your information for accuracy before submitting this form. Thank you!

Business Info

Contact Info

Employee Info

Get a Group Quote

Download Group Census

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Questions? Call (920) 243-4005

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