Untitled Document

Frank Cafaro
26 Railroad Avenue #300
Babylon, New York 11702
office phone: 631-321-6165
cell phone: 516-480-2396
fax: 631-321-6175
Email: info@cafaroinsurance.com

Home

Services

Choice Plan Selections

Group Health Form

NYS DBL Form

Life Quote Form

Individual Disability Insurance Form

Insurance Carriers
We Represent

Privacy Statement

Group Health Insurance Quote Form

For your Company to be contacted, please provide a valid phone number.

Company Name:

Contact Name:

E-mail Address:

Address:

City:

State:

Zip:

AM Phone Number:

Include Area Code

PM Phone Number:

Include Area Code

Fax Number:

Include Area Code

Number of Employees:

Business Description

If OTHER, give brief description:

Has company been in business
for over one year?

Yes No

What Percent Will Business Contribute Towards Benefit Plan?

Is There A Current Plan In Effect?

Yes No

Desired Benefits:

HMO
EPO
PPO
Dental
Vision
Life
Disability

Search Engine you found us on:

AGE	SEX	DEPENDENTS	STATUS	ZIP CODE
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female

Questions/Comments:

Thank you for taking the time to answer the questions in this request form.

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.