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Request for Group Quote
Thank you for your interest in Ternian Insurance Group.

If you would like to receive a group quote on Ternian’s products and services, please fill out and submit this online Request For Quote Form.

If you would like to download and save an RFQ Form to complete and submit it later, then Click Here.

If you do not have a quote request for a specific group, but are looking for more detailed information, then click here to complete the Contact Us Form and a representative from Ternian will follow-up with you directly.

Thank you for considering our programs.

Company Information
Business Name:
Type of Group:
Contact Name and Title:
Company Address:
City: State: Zip:
Phone:
Email Address:
Website:
Situs State: SIC Code: EIN #:
Program Information
Number of Eligible Employees: Proposed Effective Date:
Eligibility Statement (who is eligibile for this coverage):
100% Employee Paid:       If No, Employer Contribution Amount:  
Census available for eligible employees?       If Yes, please submit RFQ form.
Plans to Quote:













Current mini-med and/or
major-med plan in place:		      If Yes, Carrier:  
Agent Information
Name: Agency:
Phone: E-Mail:
Broker of Record:   
Address:
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Ternian Insurance Group LLC.
7310 N. 16th Street, Suite 228 | Phoenix, AZ 85020 | 602.216.0006
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