Request for Information

Complete the fields below to request more information and pricing.

*Required Fields

Is the requesting Employer a current client of Flex? *

Employer/Client Company Name *

Employer/Client Contact Full Name *

Employer/Client Contact Email *

Employer/Client Contact Phone *

Employer/Client Company State *

Number of Employees *

Requested Effective Date *

Year

Month

Day

Is an Insurance Producer associated with this request? *

Agency Name *

Producer Full Name *

Producer Email *

Producer Phone *

Flexible Benefits