Please
print and fill in the form, than fax it to us!
(818) 993 1497
DATE:
______/______/_____
COMPANY
NAME: ___________________________
ADDRESS___________________________________
____________________________________________
CITY_________________________ZIP____________
COMPANY
PHONE #: _________________________
CONTACT
PERSON: _________________________
NATURE
OF BUSINESS: ______________________
OPERATED
FROM A RESIDENCE? ___YES___NO
MORE
THAN 1 LOCATION
___YES___NO
LEGAL
STRUCTURE OF THE BUSINESS ENTITY:
_____
“C” Corp. ______”S” Corp ____Sole Proprietor
_____Partnership
NUMBER
OF YEARS IN BUSINESS: ____________
[“EMPLOYEES”
MUST BE W-2 - WITHOLDING]
NUMBER
OF FULL-TIME EMPLOYEES ______
(30+
HOURS A WEEK)
NUMBER
OF PART-TIME EMPLOYEES ______
(Less
than _____hours a week)
HOW
MANY EMPLOYEES WILL PARTICIPATE
IN COVERAGE? _____
_____%
OF ELIGIBLE EMPLOYEES
_____%
OF ELIGIBLE DEPENDENTS
ANY
EMPLOYEES:
PAID
BY COMMISSION? ___YES ___NO
PAID
AS INDEPENDENT
CONTRACTORS
(1099) ___YES ___NO
WORKERS
COMP RENEWAL DATE: ____/___
WORKERS
COMP CARRIER_________________
#
OF EMPLOYEES RELATED BY BLOOD_____
#
OF EMPLOYEES RELATED BY MARRIAGE___
#
OF EMPLOYEES OUT OF STATE ______
#
OF EMPLOYEES ON COBRA?
_____
TOTAL
NUMBER OF EMPLOYEES ______
NUMBER
OF UNION EMPLOYEES ______
HOW
LONG AFTER BEING HIRED IS AN EMPLOYEE ELIGIBLE? ______/Months
CAN
ALL EMPLOYEES ANSWER HEIGHT & WEIGHT QUESTIONS FAVORABLY?
____YES
_____NO
ANY KNOWLEDGE OF ANY EMPLOYEE OR DEPENDENT WITH ANY SERIOUS HEALTH CONDITIONS? _____NO YES (EXPLAIN) _________________________________________________________________________
_________________________________________________________________________
ANY
CLAIMS OVER $2500 IN LAST 24 MONTHS? NO ______ YES______
ANY
KNOWN PREGNANCIES?
NO______
YES ______ DUE DATE(S) ___________
_____________________
BENEFIT
INFORMATION:
TYPE
OF PLAN REQUESTED:
______ALL
PLANS ______HMO’S _____PPO’S
________POINT-OF-SERVICE
_______THESE CARRIERS ONLY:
_________________________________
_________________________________
CURRENT
CARRIER: ______________
PREMIUM:
$_____________
CURRENT
PLAN TYPE: ____HMO ____ PPO
_____
POS _____ MULTI/OPTION
[Please
attach copy of current bill]
WHAT
PERCENTAGE OF EMPLOYEE COST IS PAID BY EMPLOYER? ______
WHAT
PERCENTAGE OF DEPENDENT COST IS PAID BY EMPLOYER? ______
Do
you have a section 125/Cafeteria/Flexible Benefits Plan? ______Yes
______No
OPTIONAL
/ADDITIONAL BENEFITS:
_____
VISION _____ DENTAL
_____ LIFE
Telephone
(818) 888-0880 (800) 487-0880
FAX
(818) 993 1497
Postal address
P.O. Box 7265 Van Nuys CA 91409-7265
Copyright © 2006 Paul Davis & Alberta Bellisario Insurance Services