NCMS EB Plan
North Carolina Medical Society Employee Benefit Plan Quote Request
Employer Information
Employer Name (Provide complete legal name) *
Specialty *
Location Address *
City *
County *
State *
Zip *
Is the Mailing Address the same as
the Location Address given above? *
Mailing Address
City
County
State
Zip
Phone Number *
Fax Number
Email Address
Contact Person *
Title
Coverage Effective Date *
calendar
Current Carrier
Renewal Date
calendar
Referral Source
 
Census Information
Total Number of Employees Requiring Coverage *
more than 20
add1-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add2-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add3-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add4-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add5-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add6-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add7-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add8-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add9-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add10-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add11-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add12-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add13-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add14-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add15-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add16-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add17-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add18-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add19-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
add20-label
Employee First Name
Employee Last Name
Date of Birth
calendar
Coverage Type
 
More Information
Please indicate whether you would like more
information about these products:
Life/AD&D Insurance
Dental Insurance
 
 
Referring Agent
 
 
Marketed exclusively by MMIC Agency, LLC.
a Medical Mutual company
 
Contact Information
Email Support
Click here.

Phone Support (8:30-5:00 EST)
Contact NCMS Plan Sales at 800-662-7917