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Paul Muench Company

Group Health Quote

Group Health Insurance Quote

Contact Information
Group Name:
Telephone:
Group Contact:
Fax:
Group Address:
City, State & Zip:
E-Mail Address:
Current Health Carrier: Effective Date:
# of employess: Cobra Employees
How long in business:
Worker's Compensation?: Employees in waiting period:
Group Census
(If More Than 10 Employees, please call us to receive
a large group census form.)
Employee #
Birth Date (mm/dd/yy)
Gender
Zip Code
Select Coverage
# 1
# 2
# 3
# 4
# 5
# 6
# 7
# 8
# 9
# 10
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.


Contact Us

Paul Muench Company
P.O. Box 5490
Huntington Beach, CA 92615

Chris Walker: 714-689-0055
Robert Walker: 714-689-0056
Norma Brown: 714-689-0057

Fax: 657-845-4024

Email Us

Email Chris Walker:
Chris@paulmuench.com

Email Robert Walker:
Robert@paulmuench.com

Email Norma Brown:
Norma@paulmuench.com
 

 

 

 

 

 

©2009- Paul Muench Company

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