Life and Health Group Quote Request We would like to provide you with a free, no-obligation life / health group insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. (Licensed in the states of AZ, NV and CA only)

Business Information
Business Name:
Address:
City:	State: AZ CA NV Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM   PM
Contact Name:
Email Address:

Present Carrier Information
Company Name (not agency):
Current Deductible:	$
Benefits:

Details of Existing Participants
Anyone with a pre-existing condition?:	Y   N       If Yes, Please provide Details:
Any Employee or Dependent Pregnant?:	Y   N       If Yes, List Due Date(s):
Any Employee Disabled?:	Y   N       If Yes, Please provide Details:
Did any Employees or Dependents have medical claims of over $5000 in the past 12 months? :	Y   N       If Yes, Please provide details:
All Employees covered by Workmen's Comp?:	Y   N       If No, Please provide list who is not covered:

Employee Census Information
Please enter information below for all to be covered.
Employee Details			If Applicable		Select Desired Plan
Employee Name:	Sex:	Birth Date MM/DD/YY:	Spouse Age:	# of Kids:	Emp Only:	Emp +Spouse:	Emp +Child:	Emp +Family:
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F

Deductible / Coverages
Desired Deductible:	$200 $500 $1000
Coverages Desired?:	Maternity Dental Weekly Income (100/wk) Prescription Drug Card

Additional Comments/Questions

Please give any additional comments or questions regarding this quotation. If you have additional information where there was not enough space, please enter that information here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.