Group Plans

Group health insurance continues to be a key issue in employee/employer negotiations. In many industries offering competitive benefits is essential to acquire desirable employees. California law allows groups of two or more to apply for group health insurance. In many cases, this can be obtained on a guaranteed basis (without rejection due to medical reasons).

To properly assist you and provide a side-by-side comparison of the best plans and rates available, please complete the group census form below. Once submitted a group health insurance specialist will contact you via phone, email or mail (your preference) with a proposal, or with questions. Thank you for taking the time to compete this group census. By doing so we can provide you more accurate information.

Please start with our on-line form: * Required
* Group (Company) Name:	Please input 'Name'
* Telephone:	Please input correct phone number
Fax:
* Address:	Please input 'Address'
* City, State, Zip:	Please input 'City' Please input 'State' Please input 'Zip'
* Email:	Email not correct
Nature of Business:
Length of Time in Business:

EMPLOYEE CENSUS

Name	Sex	DOB or Age	Age of Spouse	# of Kids	Home Zip Code	Cal-Cobra/ Cobra
1 .
2 .
3 .
4 .
5 .
6 .
7 .
8 .
9 .
10 .
Please use comment section for additional employees

To better serve you, please answer the following questions:

Can you provide a DE6?	YES NO
Do you have Workers Compensation in place?	YES NO
Current Group Health Plan Carrier:
Reason for Wanting to Change:
Preference:	HMO PPO POS Combination
Please provide other information that may help us understand your situation:
Please submit the form and we will get started on your proposal immediately.