- Complete the following to receive quotes for groups of 2-50 eligible employees.
- Fax to 1-310-615-0994
- For information on benefits and/or underwriting, please call 1-310-615-0940.
Your Name : ____________________________________________________________________
E-mail : ____________________________________________________________________
Company : ____________________________________________________________________
Address : ____________________________________________________________________
City : ___________________________
County : ___________________________
State : California only
Zip : ___________________________
Work phone : ___________________________
Fax : ___________________________
ALL AVAILABLE MEDICAL, DENTAL AND LIFE PRODUCTS AND RATE TIERS WILL BE QUOTED
UNLESS OTHERWISE SPECIFIED...
Name of Employee: Birthdate: Home Zip Code: Spouse: # of Children:
(Last, First, M.I.)
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| Gary Jones Insurance Agency |
CA License #0E22842 |
| 508 Main Street |
310-615-0940 Phone |
| El Segundo, CA 90245 |
310-615-0994 Fax |
Blue Cross Rapid Quote Request