WINDfall Financial Group

"Authorized Agent" CA License # 0781741


	• Health insurance Individual & Families
	• Group Health Insurance
	• Life Insurance
	• Disability Insurance
	• Medicare Supplements
	• Long Term Care Insurance
	• Annuities
	• Business Insurance

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Group health insurance quote form
Name of Business:		Contact Name:
Number of Employees:		email:
Present Plan:		Day Time Phone:
Desired Annual Deductible:		Address:
Coverage Types: (check all that apply)	Health Short Term Disability Long Term Disability Dental Life
City:		State:
Zip:
Please list any medications, health issues, concerns, or comments here.