Request Information Packet

Niche Benefits will respond ASAP once the information requested below is completed. The information will allow Niche Benefits to begin to assist in providing a solution for the rising cost of benefits for the employer and their employees - saving potentially hundreds of thousands of dollars or more depending upon the size of the employer workforce covered.

Please Note: Your information will be kept confidential. It will not be shared or sold to any outside sources. Privacy Policy

Employer Information

(* = required)

First Name:*
Last Name:*
Title:*
Organization Name:*
SIC Code
Address:*
Address:
City:*
State:*	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:*
Type of Business:*
Telephone:
Number of EE's:*
Number of Employees By Class:	Full Time: Part Time: Temporary:
% of EE Turnover:	Full Time: Part Time: Temporary:
Email:*
Please provide a summary of benefits that are currently available to the employees: