Group Health Request Form
Contact Name:
Contact Email:
Group Name:
Address (1):
Address (2):
City:
Zip:
Phone:
No. years in business:
Effective Date:
Company Census:
Employee
Sex
Age
*Dep Type
Zip Code
PPO/HMO
COBRA Y/N
M
F
Y
N
M
F
Y
N
M
F
Y
N
M
F
Y
N
M
F
Y
N
M
F
Y
N
M
F
Y
N
M
F
Y
N
M
F
Y
N
M
F
Y
N
*DEP TYPE:
LO = Life Only | EE = Employee Only | ES = Employee & Spouse | EC = Employee & Child (no spouse) | EC+ = Employee & Children (no spouse) | FA = Employee, Spouse & Child(ren)
Employer Contribution:
Do you currently have a group policy?
Yes
No
If yes, please specify carrier:
Name of plan:
Do you have any preferences?
(carriers, copay, deductibles, etc)
* If you are not sure whether you would like a PPO or HMO we can present you with both options.
California License Board
Copyright © 2008. Sierra Oak Insurance Services, Inc.
9700 Business Park Drive, Suite 105 - Sacramento CA 95827
