Affordable Health Insurance Quotes

Fill Out Our Form Below to Get A Quote

So we may better assist you please answer the following questions and click submit. After we have received your information, we will review it and contact you with a quote.

For any questions please call Ben Lewis at 707-978-2359 ext. #1.

Small Business Intake Form

How did you hear about us?(Required)

Company Name(Required)

Contact Name(Required)

Nature of Business(Required)

Business Type(Required)

Sole Proprietor

LLC

C-Corporation

S-Corporation

Partnership

Other

Email Address(Required)

Business Address(Required)

Please add street address / P.O. Box, City, State, and Zip Code.

Business Phone Number(Required)

Fax Number

How Many Full-Time Employees Do You Have?(Required)

Fulltime Employees

How Many Part-Time Employees Do You Have?(Required)

Part-time Employees

Do you currently offer health insurance to your employees? If so, what carrier are you insured through?(Required)

What Kind of Medical Insurance would you like to offer?(Required)

Medical

Dental

Vision

Chiropractor / Acupuncture

Supplemental Benefits (critical illness, accident, cancer STD)

Term Life

HRA

FSA

HSA

Retirement Plans

Requested Effective Date?(Required)

Please enter the date you would like your insurance to start.

Is there anything else you would like for us to know?

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Disclaimer

This website is owned and maintained by JC Lewis Insurance, which is solely responsible for its content. This site is not maintained by or affiliated with Covered California, and Covered California bears no responsibility for its content. The e-mail addresses and telephone number that appears throughout this site belong to JC Lewis Insurance and cannot be used to contact Covered California.

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