Affordable Health Insurance Quotes Small BusinessMedicare 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 What is Your Payroll Frequency?(Required) Bi-weekly Semi-Monthly Weekly Other Do you have a bookkeeper?(Required) If yes, please enter their Full Name, Phone Number, and Email Address.Do you have business liability insurance?(Required) No. Yes I do. No, I do not want to review it. Yes, and I would like to review it I'm not sure. How long have you been in business?(Required) Less than a year 1 - 5 years 6 - 10 years 11 - 20 years 21 - 30 years 31 - 40 years 41+ years Business Address(Required) Please add street address / P.O. Box, City, State, and Zip Code.Business Phone Number(Required) Fax Number Cell Phone Number(Required) Email Address(Required) Tax ID(Required) SIC Code(Required) How Many Full-Time Employees Do You Have?(Required) 1 - 10 11 - 20 21 - 30 31 - 40 41 - 50 51+ How Many Part-Time Employees Do You Have?(Required) 1 - 10 11 - 20 21 - 30 31 - 40 41 - 50 51+ Why Are You Interested in Offering Employee Benefits?(Required)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.Do you have a carrier preference?(Required) For example, HMOs (like Kaiser, SHP, WHA) or PPOs (Like Blue Shield, Anthem)Is a national network plan appealing to you?(Required) For example, Aetna, United Health Care, Blue Cross Blue Shield.How much do you want to contribute to employee premiums monthly?(Required) For example, 50% minimum for health coverage.How much do you want to contribute to employees dependent premiums?(Required) You are not required to contribute to dependent premiums.Do you have any new supervisors that need mentorship or coaching?(Required) Do you have any managers that are struggling with burnout?(Required) Do you have any specific employees you want to invest more into?(Required) What is the most exhausting issue your managers are dealing with right now?(Required) Are you struggling to find the right employee?(Required) Are you having any issues with team conflict or productivity?(Required) Is out of work coverage important to you?(Required) Yes No I'm not sure Would you like to offer your employees a choice of carriers?(Required) Yes No I'm not sure Do you want offer benefits to employee dependents?(Required) Yes No I'm not sure Is there anything else you would like for us to know?NameThis field is for validation purposes and should be left unchanged.