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Williams Insurance Services

Please take a moment to fill out the form below and
one of our representatives will contact you with a free, no-obligation quote.
 This information will be kept confidential and will be used for quote purposes only.


Group Health Insurance Quote Request



Business Name*:


Mailing Address:


Street Address:


Contact Person*:






Business Type:

Tax ID Number:





How long has business been established in California?    years / months





Are all of your employees located in California
(51% must be in CA)?

  Yes No


Requested Effective Date:





How many employees do you have?


Eligible Employees









Full time employees (30 hours or more per week)




Part time employees (less than 30 hours per week)




W-2 only, No 1099s, Leased or Commissioned 




Ineligible Employees





New hires (still in probationary period)




Medi-Cal or Medicare eligible (over age 65)




Military coverage




Other group coverage
(i.e., spouse’s group plan, eligible dependent on parent’s group plan, or other employment)



Must enroll 75% of eligible employees to qualify for group plan


*It is the employer’s option to offer coverage to part-time employees; if exercised, employer must offer all similarly situated individuals the same coverage opportunity;

*Sole Proprietors/Partners/Corporate Officers must work at least 20 hours per week to be eligible for coverage;

*Others who may also be eligible subject to underwriting approval include seasonal workers employed by selected agricultural SIC code businesses and private household staff.


What portion of the employee premium do you plan to pay?
 *Must be either: 
at least 50% of employee monthly premium,
at least $100 per employee per month or
a percentage of a specific plan’s premium.

%  or $


What portion of the dependent premium do you plan to pay?
*not required, no minimum required.

%  or $


Will you offer benefits to part time employees
(less than 30 hours per week)? *Not required to offer

  Yes No


Probationary period/waiting period for new employees:
(90 days, 6 mos, etc.)


Do you currently carry group insurance?

  Yes No


a. If yes, list carrier name


b. Please provide a copy of last month billing and benefit structure, for comparison



Do you carry Workers Compensation Insurance?

  Yes No   
Renewal Date?                 


Provide a copy of your last quarter DE-6. (Quarterly Wage & Withholding Report submitted to CA EDD)

List employees below:


Name of Employee (Last name, First name, M.I.)

Date of Birth

Home ZIP Code

Y or N

No. of Children























 * Indicates required field



Please click the "Submit " button to send your quote request.
No coverage is in effect until bound by an insurance carrier.
This is informational only





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