San Diego Insurance Affordable: Homeowners|Business|Health|Condo|Auto



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HEALTH

QUOTE HEALTH & APPLY ONLINE

Group Health Insurance

* = Required Information

This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Group Health insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.

Proper Protection Fact Finding Questions

Of the following, what is the primary reason for quote request?	Requesting More Information Paying Too Much Decrease Work Comp Premium Other

In the order of importance, what is most important to you?	Price Service Proper Coverage

Approximately when was the last time you did a review with your agent?	Within the year Over 2 years ago Over 5 years ago Never

Would you be interested in combining your commercial insurance for additional savings?	Yes No

Do you need a group life quote?	Yes No

Reason(s) For Changing Current Insurance Provider?

Has your current company/agent failed to meet your expectations in any way?

What else must I do to earn your business?

Contact Information

Contact Name

Business Name

Address

City

State

Zip Code

Business Phone Number

Primary Phone Number To Reach You

Fax

Email *

Contact Me During?

Business Information

Is This a New Business

Yes No

Years in Business

Type of Business

Briefly Describe Your Business

More Than One Location

Yes No

If yes, where

Number of Full Time Employees

Any Independent Contractors?

Yes No

Any COBRA participants previously employed by you?

Yes No

Current Policy Information

Current Insurance Company

Current Insurance Plan Type

Current Monthly Premium

Please Fax Us With A Copy of Current Policy

Yes No N/A

Interested Policy Information

Requested Effective Date

What Type of Plan Are You Interested In

Would you be interested in going to a higher deductible & higher out of pocket max to reduce your monthly premium?

Yes No

% of Costs Paid By Employer:

% of Employees Cost

% of Dependents Cost

Employees Living Out of State?

Yes No

Type of Employees to be Quoted:

All
Salary
Management
Non-Union
Hourly

Census

Name	Gender	Birth Date (mm/dd/yy)	MEDICAL HMO or PPO or HSA	DENTAL HMO or PPO	SPOUSE (Y/N)	Number of Children	COBRA (Y/N)	Home Zip