Actuarial Quote Request
Please complete the information below to receive a no-obligation quote for actuarial services provided through the Burnham & Flower GASB funding solution.  You can expect to hear back from us with your quote and service options within the next three business days.
Municipality:
Name
Address
City
State
Zip
Contact Person:
Title	Select one Mr. Ms. Mrs. Dr.
Name
Position	Select one Attorney Board of Directors Member Clerk Elected Official Finance Director Human Resources Manager Supervisor Treasurer Other
Phone
E-mail
FAX
Plan Information:
Plan 1 Plan Name Coverages included Dental Hearing Life Long-term Care Medical Optical Prescription Reimbursement Other  # Active employees      # Retirees Premium-based  Self-funded This plan covers a collective-bargaining unit  a non-union group Cash in lieu of benefits is offered
If benefits vary by union or employment class, please complete the information below for each separate union/class.
Plan 2 Plan Name Coverages included Dental Hearing Life Long-term Care Medical Optical Prescription Reimbursement Other  # Active employees      # Retirees Premium-based  Self-funded This plan covers a collective-bargaining unit  a non-union group Cash in lieu of benefits is offered

Plan 3 Plan Name Coverages included Dental Hearing Life Long-term Care Medical Optical Prescription Reimbursement Other  # Active employees      # Retirees Premium-based  Self-funded This plan covers a collective-bargaining unit  a non-union group Cash in lieu of benefits is offered

Plan 4 Plan Name Coverages included Dental Hearing Life Long-term Care Medical Optical Prescription Reimbursement Other  # Active employees      # Retirees Premium-based  Self-funded This plan covers a collective-bargaining unit  a non-union group Cash in lieu of benefits is offered

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