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

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Cafaro 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:

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Fax Number:

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Number of Employees:

Business Description

If OTHER, give brief description:

Has company been in business
for over one year?

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What Percent Will Business Contribute Towards Benefit Plan?

Is There A Current Plan In Effect?

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Desired Benefits:

HMO
PPO
Dental
Vision
Life
Disability

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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.