4 Health Plans

Group Benefits 4healthplans.com will obtain comparative quotes from all carriers in your area. Here is a list of some of the carriers we quote: Aetna, Blue Cross, Blue Shield, CalChoice, Cigna, CIMS, Health Net, Kaiser, Nation Wide, PacAdvantage, PacifiCare, UniversalCare and UHP. Comparative Quote Request For a detailed quote at no cost or obligation please complete and email this form. Or download PDF version, print, fill-out and fax form to 1-(714) 447-1608. If you have any questions please contact us. Current Health Plan Company Name Contact Person First Name Last Name Address City Zip Phone Number Fax Number Email Group Health Group Dental Group Vision Group Life Group Disability Other 1. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ 2. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ 3. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ 4. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ 5. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ 6. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ 7. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ 8. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ 9. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ 10. First Name Last Name Sex Date of Birth Spouse # of Children Home Zip ______________________________________________________________________________ Lic. Oc33198. Benefits and carriers will vary for coverages and are subject to underwriting approval, product limitations and state availability. As a consumer submitting this inquiry for coverage details, you are providing written permission to be contacted via telephone or email to verify the accuracy of the information you've included in the questionnaire above.
© 2009 4 Health Plans, All rights reserved.

Group Benefits

4healthplans.com will obtain comparative quotes from all carriers in your area. Here is a list of some of the carriers we quote: Aetna, Blue Cross, Blue Shield, CalChoice, Cigna, CIMS, Health Net, Kaiser, Nation Wide, PacAdvantage, PacifiCare, UniversalCare and UHP.

Comparative Quote Request
For a detailed quote at no cost or obligation please complete and email this form. Or download PDF version, print, fill-out and fax form to 1-(714) 447-1608. If you have any questions please contact us.

Current Health Plan

Company Name

Contact Person First Name Last Name

Address City Zip

Phone Number Fax Number Email

Group Health
Group Dental
Group Vision
Group Life
Group Disability
Other

1. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________
2. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________
3. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________
4. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________
5. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________
6. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________
7. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________
8. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________
9. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________
10. First Name Last Name
Sex Date of Birth Spouse # of Children Home Zip
______________________________________________________________________________

Lic. Oc33198. Benefits and carriers will vary for coverages and are subject to underwriting approval, product limitations and state availability. As a consumer submitting this inquiry for coverage details, you are providing written permission to be contacted via telephone or email to verify the accuracy of the information you've included in the questionnaire above.