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Williams Insurance Services

Please take a moment to fill out the form below and
one of our representatives will contact you with a free, no-obligation quote.
 This information will be kept confidential and will be used for quote purposes only.
 

 

Group Health Insurance Quote Request

 

 

Business Name*:

 

Mailing Address:

 

Street Address:

 

Contact Person*:

Phone*:

 

Email*:

Fax:

 

Business Type:

Tax ID Number:

 

 

 

 

How long has business been established in California?    years / months

 

 

 

 

Are all of your employees located in California
(51% must be in CA)?

  Yes No

 

Requested Effective Date:

 

 

 

 

How many employees do you have?

 

Eligible Employees

 

Quantity

 

 

Owners

 

 

 

Full time employees (30 hours or more per week)

 

 

 

Part time employees (less than 30 hours per week)

 

 

 

W-2 only, No 1099s, Leased or Commissioned 

 

 

 

Ineligible Employees

 

 

 

 

New hires (still in probationary period)

 

 

 

Medi-Cal or Medicare eligible (over age 65)

 

 

 

Military coverage

 

 

 

Other group coverage
(i.e., spouse’s group plan, eligible dependent on parent’s group plan, or other employment)

 

 

Must enroll 75% of eligible employees to qualify for group plan

Notes:

*It is the employer’s option to offer coverage to part-time employees; if exercised, employer must offer all similarly situated individuals the same coverage opportunity;

*Sole Proprietors/Partners/Corporate Officers must work at least 20 hours per week to be eligible for coverage;

*Others who may also be eligible subject to underwriting approval include seasonal workers employed by selected agricultural SIC code businesses and private household staff.

 

What portion of the employee premium do you plan to pay?
 *Must be either: 
at least 50% of employee monthly premium,
at least $100 per employee per month or
a percentage of a specific plan’s premium.

%  or $

 

What portion of the dependent premium do you plan to pay?
*not required, no minimum required.

%  or $

 

Will you offer benefits to part time employees
(less than 30 hours per week)? *Not required to offer

  Yes No

 

Probationary period/waiting period for new employees:
(90 days, 6 mos, etc.)

 

Do you currently carry group insurance?

  Yes No

 

a. If yes, list carrier name

 

b. Please provide a copy of last month billing and benefit structure, for comparison

 

 

Do you carry Workers Compensation Insurance?

  Yes No   
Renewal Date?                 

 

Provide a copy of your last quarter DE-6. (Quarterly Wage & Withholding Report submitted to CA EDD)

List employees below:

 

Name of Employee (Last name, First name, M.I.)

Date of Birth

Home ZIP Code

Spouse?
Y or N

No. of Children

1

  Yes
  No

2

  Yes
  No

3

  Yes
  No

4

  Yes
  No

5

  Yes
  No

6

  Yes
  No

7

  Yes
  No

8

  Yes
  No

9

  Yes
  No

10

  Yes
  No

 

    

 * Indicates required field

 

 

Please click the "Submit " button to send your quote request.
No coverage is in effect until bound by an insurance carrier.
This is informational only

 

 

 

 

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