Home - Contact Us - For your "customized proposal quote"
HEALTHCARE BENEFIT PLANNING SINCE 1984 SERVICE OF EXCEPTIONAL QUALITY
Fax Your Completed Form To: 909-484-5202
All Items Must Be Completed In Full
Business / Group Information
Company Name:
Address:
City: State: Zip:
Primary Contact Person: Title:
Phone: Fax: E-mail:
Nature of Business:
More Than One Location: Yes No
Number of full-time employee's (30+ hours/week)
Any employees paid by commission (and/or) paid as independent contractors? (FORM 1099) Yes No
Any COBRA participants previously employed by you? YesNo(if yes, indicate on Census located below)
% of costs to be paid by employer:% of Employee cost to % of Dependent Cost
Type of Employee's to be quoted: All Management Hourly Salary Non-Union
Do you have Employee's living out-of-state?Yes No (If yes, indicate, Zip Code on Census located below)
Desired Effective Date:
Delivery Options
Proposal Type
Products
Plan Designs
Other Selected Plans
Section 125 Flex Plan HRA HSA 401K
Specific Plans (Indicate below)
Current Coverage Information
Current Health Plan:
Current Premium:
Current Plan Type: HMO PPO EPO HRA HSA POS Dual Option Self-Funded Discount Plan Rx
RAF Specials (Rate Adjustment Factors)
