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					MKD Insurance Agency
P.O. Box 4066
Menlo Park, CA 94026
CA License Number 0F95116




EMPLOYER DATA REQUEST
Company Name:
Street Address:
City, State, Zip:
Current Insurance Company(ies):
Contact Person:
Type of Business:
Phone Number:
Fax Number:
E-mail Address:



Select which plan you would like quoted:           Amount or % Paid by Employer
       Health                   Vision
        Dental                    FSA
        Life/AD&D                 Long-Term Care
        Disability
t or % Paid by Employer


         for Employee
         for Dependents
MKD Insurance Agency
P.O. Box 4066
Menlo Park, CA 94026
CA License Number 0F95116



Number of employees on COBRA:

IMPORTANT DATA NEEDED TO PROVIDE A QUOTE
KEY: EE = Employee ES = Employee + Spouse EC = Employee + Children         FA = Family
EMPLOYEE CENSUS DATA

                                                                                                                                  Monthly
                                                        EE, ES, EC,   Home Zip                        Annual Salary (required
      HMO, PPO, Kaiser   Date of Hire   Date of Birth                            Gender   Job Title                             Premium (If
                                                            FA          Code                            for Life/disability)
                                                                                                                                 available)
  1
  2
  3
  4
  5
  6
  7
  8
  9
 10
 11
 12
 13
 14
 15
 16
 17
 18
 19
 20
 21
 22
 23
 24
 25
Number of employees on COBRA:

IMPORTANT DATA NEEDED TO PROVIDE A QUOTE
KEY: EE = Employee ES = Employee + Spouse EC = Employee + Children          FA = Family
EMPLOYEE CENSUS DATA

        HMO, PPO,                                  EE, ES, EC, Home Zip
                    Date of Hire   Date of Birth                          Gender   Job Title
         Kaiser                                        FA        Code
   26
   27
   28
   29
   30
   31
   32
   33
   34
   35
   36
   37
   38
   39
   40
   41
   42
   43
   44
   45
   46
   47
   48
   49
   50
Annual Salary        Monthly
 (required for     Premium (If
Life/disability)    available)

				
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