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Brien Sullivan Agency
925 Port Washington Blvd.
Port Washington, NY 11050
Toll Free: 866-467-9888
Phone: 516-883-2100
Fax: 516-883-2123

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Supplemental Benefits

Are you covered for out of pocket expenses associated with a terminal illness?

Do to the nature of health insurance and the laws that protect you, please call our office for a quote or to discuss your options. We have experts available to answer your questions and get you protected today.

We Specialize in:

Individual and Group

Cancer Insurance

Disability Insurance

Obtain a FAST and FREE Supplemental Benefits Quote Below:

Supplemental Benefits Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!

Your Personal/Group Data:

Your Name:

Your Business Name:

Street Address:

City:

State: (Must be New York)

Zip Code:

E-Mail (REQUIRED):

E-Mail again for accuracy:

Phone:

Fax (optional):

(If more than 5 in group, contact us at: 866-467-9888 )

Please Check the Group Products your company wants
to make available to your employees:
Group Health Group Dental Group Vision
Group Life Employee Benefits
Cancer Insurance Disability Insurance

Group Underwriting Information:

Employee #1 Name	M/F	Age	Status

Occupation	Status	Currently Insured?	Plan type

Employee #2 Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type

Employee #3 Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type

Employee #4 Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type

Employee #5 Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type

Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

Employee Health Problems?
(Do any of your employees have special health problems or insurance needs? If no, write "none".)

Group Plan Needs?
(Tell us what features you want in your group plan so that we may get the coverage and benefits you are looking for!)

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