Simons Insurance Agency - Group Health Insurance

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A Service of Simons
Insurance Agency

12743 Bellflower Blvd.
Downey, CA 90242

Toll Free: 888-646-2366
Local Phone: 562-803-3101
Fax: 800-346-2245

Group Health Insurance Quotation Form

One Simple Form - takes only 2-3 Minutes!

Your Personal / Group Data

Your Name

Your Business Name

Street Address

City

State: (Must be California)

Zip Code

E-Mail (REQUIRED)

E-Mail again for accuracy

Phone (REQUIRED)

Cell Phone

Fax (optional)

(If more than 5 in group, contact us at: 800-646-2366 )

Please Check the Group Products your company wants to make available to your employees:

Group Health Group Dental Group Vision Group Life Employee Benefits

Group Underwriting Information

Employee #1 Name

M/F

Age

Status

Occupation

Status

Currently Insured?

Plan type

Employee #2 Name

M/F

Age

Status

Occupation

Salary

Currently Insured?

Plan type

Employee #3 Name

M/F

Age

Status

Occupation

Salary

Currently Insured?

Plan type

Employee #4 Name

M/F

Age

Status

Occupation

Salary

Currently Insured?

Plan type

Employee #5 Name

M/F

Age

Status

Occupation

Salary

Currently Insured?

Plan type

Currently Insured?

(If yes, list carrier, and # of years continuous. If none, type N/C)

Employee Health Problems?

(Do any of your employees have special health problems or insurance needs? If no, write "none".)

Group Plan Needs?

(Tell us what features you want in your group plan so that we may get the coverage and benefits you are looking for!)

Send my quotation via:

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Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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