moving ball Group Health Rapid Quote Request moving ball 

Your Name   : ____________________________________________________________________
E-mail      : ____________________________________________________________________
Company     : ____________________________________________________________________
Address     : ____________________________________________________________________
City        : ___________________________
County      : ___________________________
State       : California only
Zip         : ___________________________
Work phone  : ___________________________
Fax         : ___________________________

Current Carrier__________________________ Requested Effective Date___________________
Nature of Business___________________________________________________________________
Standard Industrial Classification (SIC) Code (if known)_____________________________
Please circle each product to be included in your quote.     OR Check here for all carriers, all products.
CARRIER MEDICAL DENTAL LIFE/VISION
Aetna PPO/HMO/HSA PPO/HMO/POS Life
Anthem Blue Cross PPO/HMO/HSA PPO/HMO Life/Vision
Blue Shield PPO/HMO/POS/HSA PPO/HMO Life/Vision
Cigna PPO/HMO/POS PPO/HMO --
Delta Dental -- PPO/HMO --
Golden West Dental -- PPO/HMO --
Health Net PPO/HMO/POS/HSA PPO/HMO Life/Vision
Kaiser Permanente PPO/HMO/POS/HSA PPO/HMO/FFS --
New Dental Choice -- DMO --
PacificCare PPO/HMO/POS HMO --
Safeguard Vision -- -- Vision
Sharp Health Plan PPO/HMO/HSA -- --
Spectera Vision -- -- Vision
United Health Care PPO/HMO/HSA PPO/Ind --
Vision Plan of America -- -- Vision
Vision Service Plan (VSP) -- -- Vision
Western Health PPO/HMO -- -- 
  Name of Employee:                    Birthdate:  Home Zip:     Spouse:    # of       COBRA
  (Last, First, M.I.)                                                       Children:  (Y/N)
1._______________________________________________________________yesno  _____    ______
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9._______________________________________________________________yesno  _____    ______
10.______________________________________________________________yesno  _____    ______
11.______________________________________________________________yesno  _____    ______
12.______________________________________________________________yesno  _____    ______
13.______________________________________________________________yesno  _____    ______
14.______________________________________________________________yesno  _____    ______
15.______________________________________________________________yesno  _____    ______
16.______________________________________________________________yesno  _____    ______
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27.______________________________________________________________yesno  _____    ______
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31.______________________________________________________________yesno  _____    ______
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34.______________________________________________________________yesno  _____    ______
35.______________________________________________________________yesno  _____    ______
36.______________________________________________________________yesno  _____    ______
37.______________________________________________________________yesno  _____    ______
38.______________________________________________________________yesno  _____    ______
39.______________________________________________________________yesno  _____    ______
40.______________________________________________________________yesno  _____    ______

Comments:_________________________________________________________________________________________
__________________________________________________________________________________________________
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Barricks Insurance Services
13900 NW Passage #302, Marina Del Rey, CA 90292
Phone (310) 827-7286   |   Fax   (310) 827-0256
CA License #0383850
email: insure@barricksinsurance.com