Group Health Insurance Quote Request

Please complete the following secure form to get your free, no-obligation group health insurance quote for your employees. If you have any questions as you're filling out the form, please feel free to call Wescom Insurance Services at 1-888-4WESCOM (1-888-493-7266), ext. 1080, Monday through Friday from 8:30 a.m. to 5 p.m. PST.

This is not an application for insurance. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Your Information

First Name:

Last Name:

Name of your company:

Your position:

Company address:

Street:
City:
State:
Zip

Email address:

Telephone number:

Fax number:

Best time to call:

Does your company currently have an insurance carrier?

Yes No

If you have a carrier, who are they?

If you have a carrier, what is the anniversary date of your current plan?

Number of employees in your company:

Number of employees to be covered:

What type of plan(s) do you want compared?

	HMO
	PPO
	High-Deductible (HSA-Eligible)

What do you like or dislike about your current plan?

Additional remarks or requests

How did you hear about Wescom Insurance Services?