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Lic. Patricia Hamrick
patty@seguros-insurance.net

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Your Name
Business Name
Type of Business
Street Address
City
State
Zip
Country of Residence
Work Phone
Home Phone
FAX
Your Requested Effective Date of New Insurance:
E-mail (required but kept confidential)
2nd E-mail

If using a mouse, hold down Ctrl key & click to pick multiple answers. If you received this as a fax, please circle the options:

Your desired waiting period  for New Hires to become eligible  for benefits (Pick an option) 30 days 45 days 60 days 90 days 120 days Date of Hire Will Discuss Do You Have A Preference To A Network? CCN PHCS AZ Foundation Admar AHP Multiplan

Do you have insurance coverage now? Yes No Enter their name Does your company want to share the cost of insurance with employees? Yes No Doctor co-pay desired? $15 $20 $25 $30

Which plan style   would you like?   PPO HMO Enter Remarks Below Policy Pays: 60% or more 70% or more 80% or more 90% or more 100% or more   Deductible?    $100 $250 $500 $1000 $1500 $2000 $5000

What benefits would you like  your plan to include?     (hold down Ctrl key & click to pick multiple answers) Remarks you would like to add:	Maternity Perscription Card (Generic/BrandName) $10/20 Perscription Card (Generic/BrandName) $10/30 Dental Short Term Disability Long Term Disability Wellness Benefits Short Term Medical Cobra

Below is a place to enter Census Data for the employees or members of your group.
You may wish to answer the questions below to help us here at 
International Insurance-Seguros to give you an accurate price quotation for
insurance coverage at the best price. Call us & we can help you with this step. 
The questions below are optional. If you skip the section below then 
click SUBMIT at the very bottom, Or you may enter the information,
print this page & fax it to us at the number at the top of the screen.

Full Name of 3rd person to be insured  * Date of Birth *Male/Female*  Need coverage for                          Male Female   Employee Only Employee & Spouse Employee & Spouse & Children Contractor Only Contractor & Spouse Contractor & Spouse & Children
Citizenship:
Spouse:   
Child1:    
Child2:    
Child3:    
Child4:    
Child5:    
List Additional Children/DateOfBirths/ List Any Medical Conditions of Anybody in Family:      

In each line below, list additional adults and their family members and their date of birth or age,
and any Medical Conditions & Comments. An employee & family can all be entered on one line:













Enter Comments:

        
Please let us know if someone you know might need a quote for International
Insurance, for travel, medical or life:
 

  If you are finished, & please print this page with everything you entered. 
Then click on the "Submit Form" button one time , then you will see a "Thank You" window. 
Then the information you entered on the white lines above will be sent to 
International Insurance-Seguros Inc. in confidence.  Please allow us a day to respond. 
You may also keep this form & fax your printed copy of it to International Insurance-Seguros 
at USA tel: 480-345-6834.  
  If you feel there is a communication problem with your internet connection & if you wish 
paper applications please let us know.  Information you provide to us is confidential & 
will not be disclosed to any insurance company without your permission. Do you give us
the permission to use the information you provided to allow us to provide you a quotation?
 Yes   No