Please complete the following information for your Club only.

If you are needing rate information to add an employee to your existing BGCWA plan, please do not complete this form, instead call 800-245-8813 and ask for the enrollment department.

Please fill out this form as completely as possible. Fields in RED are required.

This online form accomodates as many employees as you want to enter at one time. If you require a quote for a very large number of employees, or simply do not want to spend a lot of time at your screen entering all the required information, please email your census to [email protected] and we’ll be more than happy to process your request.

Club Information

Legal Name:

Global ID:

Address:

City:

State:

Zip Code:

Telephone:

Fax:

Executive Director:

Benefit Coordinator's Information

Name:

Title:

Email Address:

Current Insurance Information

Carrier Name:

Monthly Premium: $

Full-Time Employee Information

Monthly Premium: $