Boys and Girls Club Worksers Association
Comprehensive Employee BenefitsComprehensive Employee Benefits
Boys and Girls Club Workers Association: Reqiest for Quote
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Executive Director / Insurance Contact, please complete the following information for your entire 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 up to forty (40) employees. If you require a quote for more than 40 employees, please email your census to rbrandt@bgcwa.com.

Club Information
Legal Name 
Global ID 
Address 
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Zip Code 
Phone 
Fax 
Executive Director 
Number of FT Employees 
 
Benefit Coordinator's Information
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Title 
Email Address 
 
Current Insurance Information
Carrier Name 
Monthly Premium $
 
Employee Information and Requested Coverages
Employee NameDate of
Birth		Annual
Salary		Coverage(s) Requested
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