Framberger Employee Benefits & Insurance Services, Inc. • 805.541.0462 •
info@frambergerbenefits.com
Click here if individual insurance quote
Name of Company:
Type of Business (be Specific):
Current Health Insurance:
Carrier:
Reason for considering change:
Rates
Poor Service
Poor benefits
Other (specify)
Plan Design:
Dental
yes
no
Vision
yes
no
Does the Group have any ongoing medical problems (be specific)?
For a Quote list employees:
Employee's Name (optional)
Sex
DOB or Age
Coverage
EE = Employee Only
ES = Employee & Spouse
EC = Employee & Child(ren)
FA = Family
Spouse Age
Number of Children
John Doe, Male, 55, FA, 40, 2 Jane Doe, Female, 42, EC, 43, 1
Person to contact:
Email:
