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California Insurance QUOTE
LIFE INSURANCE
LIFE INSURANCE
• Life Insurance Quotes
Question
Group Health Insurance Quotation Form
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 (REQUIRED)
Cell Phone
Fax (optional)
(If more than 5 in group, contact us at: 800-646-2366 )
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!
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Simons Insurance Agency
CA License #0772640
12743 Bellflower Blvd. Downey, CA 90242
Toll Free: 800-646-2366
Local Phone: 562-803-9501
Fax: 888-346-2245
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