GROUP HEALTH INSURANCE QUOTE (Customized and personalized) - New Solutions May Save You Money !
CONTACT
First Name: Last Name: Phone Number (Including Area Code):
Email Address: Title:
Company Name: Type of Business: Years in Business:
Is there a DBA? If so, please list:
Legal Structure of Business:
Number of full-time employees (EE): W-2 1099 Number of employees on COBRA:
Do you CURRENTLY have group health coverage: CURRENT carrier name:
Risk Adjustment Factor (RAF): Owners enrolling in the plan (E): Do you have a payroll or DE-9C ?
Is your current plan a (Click all that apply): (Preferred Providor Organization)
(Health Maintenance Organization)
(Health Savings Account/PPO)
(Point of Service Plan)
Dr. CoPay/CoInsurance Hospital CoInsurance Hospital Deductible Annual Deductible
Would you like a quote on:
What do you like MOST about your current plan: Least:
Are you CURRENTLY working with a broker: If YES, would you consider replacing us as your Broker of Record
WE MAY REQUEST COPIES OF QUARTERLY WAGE STATEMENT,ARTICLES OF INCORPORATION,BUSINESS LICENSE
EMPLOYEE INFORMATION
LAST NAME FIRST NAME M / F DATE OF BIRTH SPOUSE NUMBER OF CHILDREN COBRA HOME ZIP CODE
INSURANCE & ANNUITIES
INCOME PLANNING
EMPLOYEE BENEFIT PLANS
BUSINESS PLANNING
Mendonca Insurance Services
949.954.4445
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(Pre-Tax Dollar Premium ONLY Plan)
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949.954.4445
