____________________
____________________
Life Insurance
Health Insurance
Disability Insurance
Long Term Care/Asset Protection
Employee Benefit Planning
Retirement Planning
Group Health/Life/Disability/Retirement Plan Quote
Please provide as much information as possible for an accurate quote.
The information is kept confidential and will be only used for the quote
.
Legal Name of Business
Contact Name
Address
Address cont.
City
State
Zip Code
Business Phone
Best time to call:
AM
PM
E-mail
Type of Business:
Sole Proprietor
Partnership
C Corporation
S Corporation
Number of Employees:
Benifit Planning Desired:
Health
Life
Group Disability
Retirement Planning
Information for Buy/Sell or Supplemental Retirement Plans
Executive #1
Executive #2
Executive #3
Executive #4
Name
Date of Birth
Sex
M
F
M
F
M
F
M
F
Smoker
Y
N
Y
N
Y
N
Y
N
Amount of Insurance for Buy/Sell Agreement
Annual Contribution for Supplimental Executive Retirement Plan
Any Health Issues
Heart
Cancer
Lungs
Heart
Cancer
Lungs
Heart
Cancer
Lungs
Heart
Cancer
Lungs
Any other Health Issues
Qualified Retirement Plan
Number of Employees
Monthly Payroll
Type of Plan Desired
401(K)
Profit Sharing Plan
Pension Plan
Employee Information for Group Health or Disability Plans
Type of Health Plan:
PPO
Co-Pay
HMO
POS
Occupation
(Disability Plan Only)
Monthly Income
(Disability Plan Only)
Dependent Status
(Health Plan Only)
Employee Name
Date of Birth:
Sex: M
F
Employee only
Employee & Spouse
Employee & Family
Employee & Children
Employee Name
Date of Birth:
Sex: M
F
Employee only
Employee & Spouse
Employee & Family
Employee & Children
Employee Name
Date of Birth:
Sex: M
F
Employee only
Employee & Spouse
Employee & Family
Employee & Children
Employee Name
Date of Birth:
Sex: M
F
Employee only
Employee & Spouse
Employee & Family
Employee & Children
Employee Name
Date of Birth:
Sex: M
F
Employee only
Employee & Spouse
Employee & Family
Employee & Children
If you are unable to list all employees you desire to cover in the spaces provided, please E-Mail or Fax us a complete list of employees.
Additional Comments:
Please give any additional comments that you feel are appropriate to complete the quotation for you. If you have any additional information, please fill out the field provided.
Click the "send form" button to send your quote request
We will respond to your submission as soon as possible.
Friedman & Associates Insurance
P.O. Box 5125
Culver City, CA., 90231
State License #0634203
310.559.6692
310.559.8469
Email:
pafins@ca.rr.com
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