Please Print, Complete
Then Fax This Form
Print as many copies of the first page of the form as you need to list all the people you want to include in your organization’s program.
Request a quote by e-mail
Fax us at 206.292.6692
Call us at 800.AHA.1778
If you are an insurance agency,
please include a fax cover sheet.
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Self-Funding Insurance Quote Form
Employee Information
| Last Name |
First Name |
M/F |
Date of Birth
or Age |
Spouse/Partner
Full Name |
Number
of
Children |
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Thank you!
If you prefer, you can mail your quote request to us:
American Health Administrators
PO Box 4586
Seattle WA 98194
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