Group Census Quote Form  

Please complete this form and click Submit Census Form at the bottom.  (Note that this Request Form was created for Internet Explorer.  Other browsers may not function.  If you are concerned about internet privacy, please fax or call us.) 

Minimum size group = an owner + one employee on W-2.  If your group has full-time 1099 employees, we must have at least one employee on W-2 payment status.  

How would you like us to contact you?

      Telephone          e-mail           Fax         U.S. Mail

What Group Insurance information would you like?   

      Medical Plans

                 HMO       PPO         HSA (Health Savings Accounts)     

       Dental

                 HMO       PPO

       Vision

       Life

       Disability

       Long Term Nursing Care

   Required Information*

Contact Name*                  

Company Name*               

Nature of Business*         

Date Business Started*   

Your California DE-6 Quarterly Wage and Withholding Report (most recent quarter): 

     How many Full-Time W-2 Employees are listed on the DE-6?*     

     Of those that are listed, how many are enrolling in new insurance?*          

City in California*               

County in California*         

Zip Code*                           

Contact Information

E-Mail      

Primary Phone        

Best Time for Primary Phone?     

Alternate Phone   

FAX                       

          Employee Name/Initials (Optional)   Age    Home Zip      Dependents

If more than 20 employees, just Submit Census again with additional...

Current Insurance Company   

Please include any questions or comments below:

  Questions?  T: 1.800.994.2583 Toll Free in California

Fax:  760.438.2721

Click here to send an e-mail to us with any questions 

      Thank you for your time and interest.