Account Information

Business / Entity Name *

Address *

City *

State *

Zip Code *

When was your company established? * +

Number of U.S. Employees *

HR Contact *

Title *

Phone *

HR Contact Email *

Are you working with a broker? *

Yes

Please enter your broker's name and company: *

Please enter start date of estimated enrollment period * +

Acceptance

HR Representative *

Date * +

HR Representative Signature *

clear

(By signing this form I acknowledge that I am authorized to offer Figo to our employees as a voluntary benefit with open enrollment.)

All information submitted in this form will be securely transfered to Figo Pet Insurance.

Any questions or concerns feel free to call Figo at (844) 738-3446.