OM Insurance
Services
Quick Response - Excellent Service -
Competitive pricing
Lic
# 0D51251, Tel: (408) 261-0884,
Fax: (408) 516-9789,
www.sdif.biz ,
e-mail pal@sdif.biz
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Name of Business |
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Web site URL
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Main Office Street Address |
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# of full time employees |
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County, City and Zip |
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# of part-time employees |
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Phone # |
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Present carrier |
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Fax # |
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Renewal date |
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E Mail of Contact |
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Name of Contact
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What do you do ? Type of business ? Be specific |
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Who is your Workers Compensation Carrier: Farmers
Insurance |
Renewal Date: Company: |
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Employer Contributes what % of
the premium |
For Employee |
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For Employee’s Dependents |
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Any ee’s on Cobra ? ( Y or N ) |
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Anyone pregnant? ( Y or N ) |
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Any other major medical condition? Y or N |
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Check the benefits that you
would like us to include in your quote
You are not under any obligation to purchase any product quoted (
place X in Box)
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Medical |
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Dental |
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Long term disability |
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Group life insurance |
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Prescription drug cards |
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Key Man Life Insurance |
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Maternity full coverage |
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Workers compensation |
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General and Professional
Liability |
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Additional life insurance |
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Vision |
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Pre Paid Legal |
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Medical Plans you would
like to have: circle all that apply |
HMO |
PPO |
POS |
Indemnity |
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(Please
include copy of most current bill of your current plans)
Dependent Status* E =Employee, ES=Emp +
Spouse, EC= Employee plus
Child/Children, F=Family
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Employee Name (Optional) |
Annual Salary (optional for disability and Life Insurance) |
AGE or DOB |
Sex |
Dependent Status * |
Home Zip Code (and State if out of CA) |
Preferable Physician of
Choice (not necessary) |
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* Dependent
, E=Employee, ES=Employee and Spouse , EC=Employee, F=Family
Please make additional
copies if required.
High
Priorities (check appropriate box's)
This will
help us to focus on marketing the right co. and product:
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Lower
Current Premiums |
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Improve
Current Benefits |
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Sec.
125 Program / Cafeteria Plan |
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Show Partial Self-Insured Concepts |
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Employee’s will be in other States besides CA
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This will
help us focus our attention on areas that concern you:
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Present
Concerns or Dislikes |
A= Excellent B= Pleased C= Concerned D= Displeased
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Premiums |
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Benefits |
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List
of Providers |
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Claims
Service |
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Agent
/ Broker Service |
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Other: |
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Other: |
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Name of Current Broker |
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You may fax 408-516-9789,
e-mail: pal@sdif.biz, or mail this information to:
4301,