If your Company is considering Group Health Insurance for your firm,
 We can provide several options and plans for you consideration.

Blue Cross of California Small Group Quotes

Group Health Quote Request

The quote you have requested requires that you complete the following survey as completely and accurately as possible.  Once submitted the information will be e-mailed to our office(s) and we will expedite your request.  This information will be kept confidential and will be used for quote purposes only.  We look forward to serving you.

 

Fields marked with a Red asterisk * are required.

Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information
* Company Name:
 Company Address:
Company City:  State:   Zip:
Type of Business:
SIC Code:
* Your Name:
* Your Home Zipcode:
 Your Phone: * Work:
* Home: 
 Fax: 
* Your Email Address:

Type of Coverage

 Doctor Visit Copay: Yes   No
 Prescription Copay Card: Yes   No
Plan Type:

Hospital Deductible:

Coinsurance:
Group Life: Yes   No       Amount:
 Group Dental: Yes   No
List any specific companies you would like quotes from:
List any major medical conditions associated with this group:
(cancer, diabetes, heart)

 

Employee Census
Please list all employees you wish to cover:
Employee Name
Date of Birth (DOB)

Gender

Spouse DOB
(if applicable)

# of Children

Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
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If you have more than 15 employees, simply submit this form additional times.  You will only need to enter the company name on the other submissions.

Additional Considerations/Requests
Please give any additional comments you feel appropriate for this quotation.


Please click on the "Submit Request" button to send us your quote request.

    

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We are licensed for life and annuity products in California, Alabama, Florida, Texas, Michigan, Missouri and Indiana.

Hammond Insurance Services
Troy, MO 63379 CA USA
Phone: (636) 528-4016 • Toll free: (800) 601-5433
Email Address:insurance@wequote.com • Web Site:www.wequote.com
MO Lic# 8025920 • CA Lic# 0593641