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
Select 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)?
Requested Effective Date:
Select the effective date
1st of the next month
15th of the next month
How many employees do you have?
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
New hires (still in probationary period)
Medi-Cal or Medicare eligible (over age 65)
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.
Will you offer benefits to part time employees (less than 30 hours per week)? *Not required to offer
Probationary period/waiting period for new employees: (90 days, 6 mos, etc.)
Do you currently carry group insurance?
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
Spouse? 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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