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California Health Insurance Plans

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If you are interested in working with Professional Benefits & Insurance Services, please use the form below. We will not share the information you provide with any other person, company, or organization.

First Name:

Last Name:

Company Name:

No. of employees:

Address:

Telephone:

Fax:

E-mail:

I would like to receive periodic e-mail updates: yes     no

I would like to get periodic updates by snail mail: yes     no

I am interested in:

Specifically, I would like information on:

Health Insurance Vision Insurance

Dental Insurance Short-Term Disability

Life Insurance Long-Term Disability

Retirement Plan Other

Deferred Compensation

Message:

Life Insurance Needs Analysis

Immediate Money Fund $___________ $____________

This fund is for the bills presented after death, which will have to be paid. They may include:

Medical and hospital expenses

Federal Estate Taxes

Burial expenses

State death taxes

Attorney’s/Executor’s fee

Probate court costs

Debt liquidation $___________ $____________

Total of installment credit

School and auto loans

Unpaid notes

Outstanding bills

Emergency Fund $___________ $____________

This fund is for unexpected bills not readily payable from current income. Such things as: major repairs to the home or automobile, medical emergencies, etc.

50% of the higher wage earner’s annual income may be sufficient..

Mortgage/Rent Payment Fund $___________ $____________

What would it take to pay your mortgage off today?

What amount is sufficient for a ten-year rent fund?

Monthly rent $__________x 120mo. = $_____________

Child/Home Care Fund $___________ $_____________

To pay for new expenses created as a result of the death of a spouse formerly performing these duties without any cash outlay.

You: Amount per year $_____________x__(factor)____= $___________

Spouse: Amount per year $__________x___(factor)___ = $___________

Educational/Vocational Fund $___________ $_____________

The cost of a four-year undergraduate education or comparable vocational training will vary by state and typed of school.

Subtotal $___________ $_____________

Total of current savings, other liquid assets and existing life insurance -$___________ -$____________

New capital required $__________(A)$___________(B)

First Name:
Last Name:

Company Name:
No. of employees:

Address:




Telephone:
Fax:
E-mail:

I would like to receive periodic e-mail updates:		yes no

I would like to get periodic updates by snail mail:		yes no

I am interested in:
Specifically, I would like information on:
Health Insurance		Vision Insurance
Dental Insurance		Short-Term Disability
Life Insurance		Long-Term Disability
Retirement Plan		Other
Deferred Compensation
Message: