I, as a representative for the within named Group, hereby certify, represent and warrant that the information provided on this Request for Proposal is true, accurate and complete in all aspects and I acknowledge that such information is intended to provide Insubuy®, Inc. with information necessary to evaluate this Group and provide the Group with premium and coverage indications.
I understand that by submitting this form, I am appointing Insubuy®, Inc. as a broker of record for the above group. I can revoke the broker of record only with a 60 days prior written notice.
Upon submission of this request, I understand that more information may be required in order to get accurate quotes and I agree to coordinate in providing the necessary details promptly.
Final rates and coverage will be based on the actual enrollment, including evidence of insurability, if applicable. No insurance shall be effective unless and until the Group is notified in writing by the insurance company.