Alternative Health Insurance Services

Providing Benefits for Groups and Individuals since 1985

(800) 331-2713



	Providing Benefits for Groups and Individuals since 1985


	Group Quote Request


	Name of Company/Business:


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	Type of Business:


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	Are all full time employees being covered on this plan?


	Yes


	No


	If no, please explain:


	Are all employees to be covered actively at work?


	Yes


	No


	If no, please explain:


	Are any employees currently absent due to illness, disability or extension of coverage (including COBRA?)


	Yes


	No


	If yes, please provide details:


	Are any employees or dependents currently pregnant?


	Yes


	No


	If yes, please provide delivery date(s) due:


	Is anyone to be covered being treated or has anyone been recommended to receive treatment for any major health condition (i.e. heart, cancer, tumor, AIDS, alcohol/substance abuse, kidney, etc.)?


	Yes


	No


	If yes, please provide details:


	Will this coverage replace an exisiting group plan?


	Yes


	No


	If yes, please provide name of present carrier:


	Current Rates


	Renewal Rates


	Please Complete the following Census Information in the area below:


	Employee Name


	Age or birthdate


	Age of Spouse, Number of Children


	Home Recommended Links [Individual Quote Request] [Group Quote Form] [Provider Request Form]


	Alternative Health Insurance Services 117 Bernal Road # 70-205 San Jose, CA 95119 Phone: (408) 223-1787 Fax: (208) 567-2507


	If you would like to contact us via e-mail: Then simply click here: Alternative Health Insurance Services

Alternative Health Insurance Services
Providing Health Insurance Benefits for Groups and Individuals since 1985
117 Bernal Road #70-205
San Jose, CA 95119
California Insurance License #0F27218 / 0B98166
Illinois Insurance License for Health and Life
Toll-free: (800) 331-2713
Fax: (208) 567-2507
www.AlternativeInsurance.com

If you would like to contact us via e-mail:
Then simply click here:
Alternative Health Insurance Services