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Request a Group Quote    [ Click here for an Individual Quote ]
To receive a free, no-obligation quote for your business, simply fill out the information below and click "submit".
Or click here to print out the form, complete it offline and fax to us at 425-329-2019.

Note: Your information is protected by HIPAA guidelines and is never sold to third parties.

What type of coverage are you looking for? Check all that apply.

Health Dental Life Disability
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Contact:
Address1:
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Preferred contact method: Phone Fax Email


For Health Insurance Quotes Only
Do you currently have group coverage? Yes No
If no, continue to Employee Census information.
Carrier Name:
Total Monthly Premium:
Deductible Amount:
Office Visit Co Pay:
Rx Co Pay: 1   2   3
Renewal Month:


Your Employee Census Information
If you have more that twelve employees, click here to print a blank census form. Complete offline and fax to 425-329-2015. Write ?Fax Census? below under Name in position 1 and submit your request. Thank you.
  Name Gender Date of
Birth
MM/DD/YYYY		 Enroll
Spouse?		 Spouse Date of
Birth
MM/DD/YYYY		 Enroll Children?
1 Male   Female Yes   No Yes  No
2 Male   Female Yes   No Yes   No
3 Male   Female Yes   No Yes   No
4 Male   Female Yes   No Yes   No
5 Male   Female Yes   No Yes   No
6 Male   Female Yes   No Yes   No
7 Male   Female Yes   No Yes   No
8 Male   Female Yes   No Yes   No
9 Male   Female Yes   No Yes   No
10 Male   Female Yes   No Yes   No
11 Male   Female Yes   No Yes   No
12 Male   Female Yes   No Yes   No




Diamond Benefits Insurance Services      |     19203 36th Ave W Suite 205      |      Lynnwood, WA 98036      |      Phone: 800-337-6177      |      Fax: 425-329-2019
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