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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

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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.

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Palomino Insurance Agency

Corporate Office

8889 E. Bell Rd #201
Scottsdale, AZ 85260
Office # 480-483-8000

California Office

Serving Los Angeles, San Diego
& Orange County
26359 Jefferson Ave #D
Murrrieta, CA 92562
Office # 949-300-2050

License Information:

AZ Palomino Agency Department of Insurance License #910284
AZ Mike Palomiono Az Department of Insurance License #704684
CA Individual Approved License #0H39335
CA Broker Corp LIC #OH58343
UT Mike Palomio Individual. #375139