• 1.Contact Information
  • 2. Request Contact or
    Complete Online
  • 3. Company
    Information
    Locations
  • 4. Current Benefit
    Plans
  • 5.Plans to Quote
  • 6.Census Data
  • 7.Large Claims Data
  • 8.Claim History Data
  • 9.Comments
  • 10. Complete

Having Trouble?

If you need help with the RFQ process, then click the "Contact Me" button below, and a sales representative will contact you.

Contact Me

Quote Request

* Indicates a Required field

Welcome to the ASR Health Benefits' online quote request form! This form is quick and easy to complete. Simply enter the requested information in the boxes, noting the required fields marked with an asterisk, and click the red CONTINUE button at the bottom of each page. When you have completed each section, ASR will generate a quote and return it to you.

Before You Begin

You will be required to enter Census data for your company in order to complete the RFQ, as well as Large Claims data if applicable. You may either enter the information into our web form, or you may download an Excel file and enter the information there. If you would like to enter your census information and/or large claims into the Excel file, then you may download our Census Data template or the Large Claims Data template. If you are requesting a Self-Funded Quote, we also require that you upload or enter any large claims data and your claims history.

Are you an employer or an agent? *