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Business Contact

Contact Name: *
Business Name: *
Business Description: *
Business Address: *
City: *
State: *
Zipcode: *
Business Phone: *
Business Fax:
County: *
Current number of full-time employees eligible for group employee benefits: *
- One Person - Two Person - Family (3+)
List Chamber of Commerce and other business/industry associations to which your company belongs:
Current group benefits carriers, if any:
Health: * Life: Disability: Other:
Current group insurance agent’s name: *
Group Employee Benefit Needs:	Health Life Disability Voluntary Life Voluntary Disability Other Voluntary Worksite Products Section 125 Administrative Services Summary Plan Description
How else can we Assist you?

* Indicates Required Fields

Grotenhuis is an Authorized Independent Managing Agent for Blue Cross Blue Shield of Michigan and Blue Care Network. Blue Cross Blue Shield of Michigan and Blue Care Network are non-profit corporations and independent licensees of the Blue Cross and Blue Shield Association.