Group Health Quote

Valley Center Insurance Agency, Inc.

Group Health Quote

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Your most recent group health premium invoice has all of the information we need to develop a quote. If you prefer, you can fax your invoice to (760) 749-0622 or E-mail it to: mailto:Rick@vciainc.com

If your business has 10 or more employees, let us do all of the typing. Just fax or E-mail your group census information to us.

Your name
Company name
Company street address
City
Zipcode
10 digit phone number
Current insurance carrier
Current rate adj. factor (RAF)
Policy renewal date
HMO plan name
HMO office visit copay
PPO plan name
PPO office visit copay
Do you offer medical insurance?
Do you offer dental Insurance?
Do you offer vision insurance
Do you offer life / disability?
Name of employee #1
Age of employee #1
Zipcode employee #1 resides in
Employee #1 coverage option
Name of employee #2
Age of employee #2
Zipcode employee #2 resides in
Employee #2 coverage option
Name of employee #3
Age of employee #3
Zipcode employee #3 resides in
Employee #3 coverage option
Name of employee #4
Age of employee #4
Zipcode employee #4 resides in
Employee #4 coverage option
Name of employee #5
Age of employee #5
Zipcode employee #5 resides in
Coverage option for employee #5
Name of employee #6
Age of employee #6
Zipcode employee #6 resides in
Employee #6 coverage option
Name of employee #7
Age of employee #7
Zipcode employee #7 resides in
Employee #7 coverage option
Name of employee #8
Age of employee #8
Zipcode employee #8 resides in
Employee #8 coverage option
Name of employee #9
Age of employee #9
Zipcode employee #9 resides in
Employee #9 coverage option

Valley Center Insurance Agency, 27525 Valley Center Rd., Suite B. Valley Center, CA. 92082 Ca. lic. no. 0E48178 Ph. (760) 749-0622 Fax. (760) 749-0628