License #0467457

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Life & Health Insurance

From one person to 1000+ employees PIA has a competitive Health Insurance program for every situation. Let us shop your individual or group health insurance for the best possible price and coverage. We offer coverage with the leading HMO and PPO's.

Blue Shield, Blue Cross, Lifeguard, Kaiser, Pacificare, Healthnet, United Healthcare, Aetna, Cigna, Humana, Lincoln Benefit, PAC Health Advantage, Prudential, PM Group, VSP, Delta Dental

COMPANY INFORMATION:
Company Name:		Type of Business (Be Specific:)
Business Address	City	State	Zip
County	Phone	Fax	Email
Contact Person	Current Health Carrier
Type of Health Plan HMO PPO Dental Vision   Chiropractic    Mental Health   Prescriptions  Life    AD & D

 

EMPLOYEE INFORMATION
#	Employee Name	Zip Code	Date of Birth	Dependents to be covered		Life Insurance Amount	Dependent Life Amount
				Spouse	# of Children
1.				Yes No
2.				Yes No
3.				Yes No
4.				Yes No
5.				Yes No
6.				Yes No
7.				Yes No
8.				Yes No
9.				Yes No
10.				Yes No
11.				Yes No
12.				Yes No
13.				Yes No
14.				Yes No
15.				Yes No
16.				Yes No
17.				Yes No
18.				Yes No
19.				Yes No
20.				Yes No

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