Contact Name
Title
Company Name
Street Address
Address (cont.)
City, State  Zip	,
Phone
FAX
E-mail

	HMO plans		PPO plans		Healthcare Savings Account Plans (HSA)
	Dental		Vision		Life
	Long or Short Term Disability				Long Term Care

Which carriers/companies do you want to consider?

Medical Plans:
	Aetna		Anthem Blue Cross		Blue Shield of Calif
	California Choice		CIGNA		Health Net
	Kaiser		PacifiCare		United Healthcare
	Don't care - Carrier selection is strictly price driven
Dental Plans:
	Ameritas		Delta Dental		Golden West
	Guardian		Humana		Principal Financial
	SafeGuard
	Quote dental plans through the medical carriers selected above
Life Insurance:
	$25,000		$50,000		$100,000
	1x Salary		2x Salary		Tiered by job category
If available, the life insurance will be through the selected medical or dental carrier.
Vision Plans:
	Vision Service Plan (VSP)		Medical Eye Services (MES)		Vision Plan of America (VPA)

What do you expect the coverage to cost per employee per month?

Medical Plans:
	$100-$150		$150-$200		$200-$250
	$250-$300		$300-$350		$350+
Rates are set by the carriers underwriting departments, not brokers...your selection has no effect on quoted premiums. Out of the hundreds of available plans, your budget simply gives us an idea which plans to quote
Dental Plans:
	<$20		$20-$30		$30-$40
	$40-$50		$50-$60		$60+
(Roughly <$20=Dental HMO    $25-$45=Dental PPO    $50 up=Visit any Dentist    Best plans are $60+)

Enter your census in the space provided below.

Name	Sex		Age	Spouse to be covered?	Number of Children?
	M	F		Check if Yes

If you have more than 15 employees, send us a second form.
Please put the company name on the second page.