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


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Mendonca Insurance Services
949.954.4445
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