Questions?
Ask the Agent! Use the form below
or give us a call.
Phone: (800) 750-8888
Fax: (866) 353-3083
Group Health Insurance
One Simple Form - takes only 2-3 Minutes!
YOUR PERSONAL | GROUP DATA:
Your Name:
Your Business Name:
Street Address:
City:
State: (Must be California)
Zip Code:
E-Mail: (Required)
E-Mail again for accuracy:
Phone:
Fax (Optional):
Your Company Website:
(If more than 5 in group, contact us at: 800-750-8888 )
Please Check the Group Products your company wants to make available to your employees:
Group Health
Group Dental
Group Vision
Group Life
Employee Benefits
GROUP UNDERWRITING INFORMATION:
Employee #1 Name
M/F
Age
Status
Occupation
Status
Currently Insured?
Plan type
Employee #2 Name
M/F
Age
Status
Occupation
Salary
Currently Insured?
Plan type
Employee #3 Name
M/F
Age
Status
Occupation
Salary
Currently Insured?
Plan type
Employee #4 Name
M/F
Age
Status
Occupation
Salary
Currently Insured?
Plan type
Employee #5 Name
M/F
Age
Status
Occupation
Salary
Currently Insured?
Plan type
Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)
Employee Health Problems? (Do any of your employees have special health problems or insurance needs? If no, write "none".)
Group Plan Needs? (Tell us what features you want in your group plan so that we may get the coverage and benefits you are looking for!)
Send my quotation via:
E-Mail Fax Regular Mail Call Me by Phone
Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
Yes, I Agree. Please Send Me a Group Insurance Quote NOW!
Click Button Below When Done
Please Click Only Once . . . May take up to 30 seconds!
HAD / Professional Insurance Associates, Inc | Mailing Address: P.O. Box 8480, Porter Ranch, CA 91327
1100 Industrial Road, Suite 3, San Carlos, CA 94070 | 6320 Canoga Avenue, Suite 1500, Woodland Hills, CA 91367
Terms of Use / Privacy Notice / Copyright Information
