Employee Benefits

Please complete the form below to receive a free quote.

Quote Request form
Company Name:
Contact Name:
Address:
City:
State:
Zip:
Phone:
Work Phone:
Fax:
Email:
Type of Business:
Year Established:

Enter your census data
If you have more than 9 employees: fill out the employee fields on this form and click the "Submit" button. Return to the form, enter just your company name, the remaining employee information, and click "Submit" again. You may repeat this process as often as necessary.
Name Age DOB (mm/dd/yy) Sex Spouse No. of Children
1. M
F 		Y
N
2. M
F		 Y
N
3. M
F		 Y
N
4. M
F		 Y
N
5. M
F		 Y
N
6. M
F		 Y
N
7. M
F		 Y
N
8. M
F		 Y
N
9. M
F		 Y
N

Type of Coverage Desired
PPO (Preferred Provider Organization): Yes No
HMO (Health Maintenance Organization): Yes No
POS: Yes No
Disability: Yes No
Dental: Yes No
Life Insurance: Yes No
JWB Insurance
P.O. Box 4849
Wilmington NC 28406
Phone: (910) 799-5453
Fax: (910) 313-2722
Toll Free: (866) 799-5453
531 Keisler Drive Suite 104
Cary, NC 27511
Phone: (910) 799-5453
Fax: (910) 313-2722
Toll Free: (866) 799-5453