Custom Benefit Analysis Request
Name of Company:

Name of Contact Person:

Job Title:

Phone:
Address:
City:
State:
Zip:
E-mail:


Steven A. Ehlen, Agent #HFBE6161
MN Insurance license #200889301

Holland & Frank Executive and
Employee Benefit Solutions, Inc
Independent Agent for Blue Cross Blue Shield of Minnesota
1101 2nd St. S. Suite 110
Sartell, MN 56377

 Office:       (320) 252-2799
Toll-free:   (888) 577-1142
Fax:            (320) 257-4584
                   (877) 577-5437

E-mail: steve@hollandandfrank.com
How many employees are benefit eligible?

Do you currently have a group health plan?
Yes
No

Who is current insurance carrier?

Do you currently us an agent?
Yes
No

Who?

When would you need coverage's?

When is the best time to contact back via phone: Date/Time

Any additional information you would like to provide before we speak?
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custom benefit analysis.