Individual & Family Proposal Request
CA Corporate License #0I31557 | 21235 Hawthorne Blvd #200, Torrance, CA 90503
* Starred fields are the minimum required for California carriers to calculate an accurate rate.
Questions? Call (310) 533-8877 or (800) 951-6456
1. Applicant Contact & Coverage Preferences
We never sell or share your information
CA
*Coverage Needed:
Medical
Dental
Vision
Life
Network Preference:
PPO
HMO
HSA
Open / Compare Both
2. Family Members to Be Covered (Required for Accurate Rates)
Please check Gender & write full MM/DD/YYYY birthday for each person
Important Note: California insurance carriers calculate rates using the exact Date of Birth (MM/DD/YYYY) and Gender of each family member being covered. Please complete both highlighted columns for every person needing coverage.
| *Relationship | First & Last Name (If Different) | *Gender (Required) | *Exact Date of Birth (MM / DD / YYYY) |
How Often Do You See the Doctor? |
|---|---|---|---|---|
| Applicant (Self) | M F | ___ / ___ / _____ | Rarely / Mod / Often | |
| Spouse / Partner | M F | ___ / ___ / _____ | Rarely / Mod / Often | |
| Child 1 | M F | ___ / ___ / _____ | Rarely / Mod / Often | |
| Child 2 | M F | ___ / ___ / _____ | Rarely / Mod / Often | |
| Child 3 | M F | ___ / ___ / _____ | Rarely / Mod / Often | |
| Child 4 | M F | ___ / ___ / _____ | Rarely / Mod / Often |
* Dependent children are eligible to remain on a parent's health plan up to age 26.
3. Important Doctors, Hospitals & Prescriptions to Verify
Helps us check that your preferred physicians are in-network
Preferred Medical Groups / Hospitals:
Torrance Memorial (TMIPA)
Providence Little Co. of Mary
UCLA Health
Optum South Bay
Kaiser
Doctor Names & Cities (Primary Care / Specialists / Pediatricians):
Ongoing Prescriptions or Upcoming Medical Needs (Optional):