Cafaro Group Health Insurance Quote Form
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Life Quote
About Us
Disability Insurance
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Group Disability
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Company Name Contact Name: Address: City: State:
Zip:
AM Ph# (Inc Area Code) PM Ph# (Inc Area Code) Fax Ph# (Inc Area Code)
Number of Employees Business Description RETAIL WHOLESALE SERVICE PROFESSIONAL FOOD SERVICES OTHER If Other Give Brief Description Has Company Been In Business For Over One Year? YES NO What Percent Will Business Contribute Towards Benefit Plan? 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% OTHER Is There A Current Plan In Effect? YES NO
Desired Benefits
HMO
YES NO
PPO
DENTAL
LIFE
VISION
DISABILITY
Employee Information If You Have Already listed More Than 12 Employees, Skip This Section. We Will Need to Contact You For An Employee List.
AGE
SEX
#-OF DEPENDENTS
STATUS
M F
1 2 3 4 5 6 7 0
Employee Employee/Spouse Single Employee w/children Family
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I understand that this service merely provides a proposal request and is not a Policy of Insurance, Application or Offer to Insure on behalf of any Insurance Company, Agency or Agent. Individual companies reserve the right to accept, reject or modify a proposal after investigation and review.
