Info > Quotes > Long-Term Care Insurance

Group Health Quote Request

You no longer have to contact every carrier you want a quote from individually for group health. We own the premier group health proposal software that allows us to gather information from every available provider in Southern California that we can present in one easy-to-understand format to make sure you get the best plan for your situation.”

In order to get you accurate information please complete the following survey as completely as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. We look forward to serving you.

Fields marked with a Red asterisk * are required.

Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information

* Company Name:

Company Address:

City:

State: Zip:

Type of Business:

* Contact Name:

Phone:

* Work:

* Home:

* Cell:

Fax:

* Your Email Address:

*Best date and time to be reached in the next 48 hours.

Date:		/
	MM	/	DD

Time:

Type of Coverage
Please list any desired coverage information, if known (plan type, copays, deductibles, etc.):
Plan Type	HMO PPO POS HSA
Group Life:	Yes No Amount:
Group Dental:	Yes No
List any specific companies you would like quotes from:
List any major medical conditions associated with this group: (cancer, diabetes, heart)

Employee Census
Please list all employees you wish to cover:
Employee Name	Date of Birth (DOB)	Gender	Spouse DOB (if applicable)	# of Children
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
		Male Female
If you have more than 15 employees, simply submit this form additional times. You will only need to enter the company name on the other submissions.

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation.

Please click on the "Submit Request" button to send us your quote request.

Dominion Financial Group, Inc.
5520 Wellesley St., Suite 203
La Mesa, CA 91942
Click here for Google map
(619) 644-3545 – Office
(619) 644-3550 – Fax

Securities offered by a Registered Representative of Sammons Securities Company, LLC. Member FINRA / SIPC.

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Group Health Quote Request

Contact Information

Type of Coverage

Employee Census

Additional Considerations/Requests