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 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 EmployeesHow Many Part-Time Employees Do You Have?(Required)Part-time EmployeesDo 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?CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.