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Group Medical Insurance Quote Request Form

License #OB17048
Q&A Insurance Marketing, Inc.
Kuhtz Diehl Insurance and Financial Services, LLC
Steven C. Kuhtz Robert W. Diehl
2080 N. Winery Ave, Suite #101
Fresno, CA 93703
Telephone: (559) 454-5060
Facsimile: (559) 251-0506

Authorized agents for: Blue Cross, Blue Shield, Kaiser, Aetna, Health Net, Cal-Choice, PacifiCare, Nationwide and many more.		 Exclusive agents for the Central California Builders Exchange medical insurance program. Offering Kaiser, Health Net, Metlife Dental Life and Disability, VSP Vision Plans, American Specialty Health Plans of Cal. with Chiropractic and Acupuncture.
  • Self Funding
  • HSA / HRA
  • Wage Hour Banking
  • Multi Choice Options
  • Service your current plan
Employer Information
   
 Employer Name:
 Address:
 City, State, Zip:
 Telephone:
 Fax:
 Contact:
 
Current Plan Information
   
 Insurance Company:
 Office Visit Copayment:
 Plan Type:
 I Am Interested In:
 (check all that apply)
 
 Employee Name
 Sex
 Age
 Spouse Covered?
 # of Children Covered
 Zip Code
           
 Change Image

Please enter the numbers displayed above:
 
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