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Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Refer A Business or Individual to Century Benefits Group, Inc.
We love referrals! The greatest testament that our customers can provide is by referring their business associates and friends. Thank you for your referral, and we thank you even more for your continued business.
Your Information:
First Name
Last Name
ZIP / Postal Code
E-Mail Address
Company or Individual to Refer:
Company Name to Refer (if applicable)
Name of Individual to Refer
E-Mail Address to Refer
Primary Phone #
Comments you wish to Add?
Please enter any comments here (if applicable):
Thank you for your referral!
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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400 White Spruce Blvd. Suite C | Rochester, New York 14623
Local: (585) 224-8138 | Toll Free: (800) 458-7805 | Email:mking@aboutcentury.com
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