Free Group Health Insurance Quote

Barragan Insurance Agency

1132 Suncast Lane Ste 8

El Dorado Hills, CA 95762

Phone: 916-984-9320

Fax: 916-984-8013

Nature of Business	# of Full Time Empl (30+/week)	% Empl Costs Employer pays	% Dependant Costs Employer pays	Type of Employee to be Quoted

Current Health Plan	Current Premium	Current Health Plan Type	Are You a PEO?	Does Group have Current Dental Coverage?	If Yes, Number of years?	% of Participation?

Employee ID	Enter E=Employee S= Spouse D- Dependant	Last Name, First Name	Date of Birth (XX/XX/XXX)	Gender	Zip Code	Is Employee on COBRA? (required)

Are there More than One Location (Other Location(s))	If Other Location(s) - Where?