SCL Insurance Agency., Inc.

* 1650 Sycamore Avenue, Suite #3, Bohemia, NY 11716 *

* Phone: 631-738-1110 * Fax: 631-738-0312 *

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Group Health Insurance Quote Request

Basic Address Information     (Required fields are marked with *)
*  Firm Name
*  Address
*  City *  State Zip:

Please supply either a Daytime or Evening Phone Number " best time to call.
    Day Time Number:
    Evening Number:
*  Best Time To Call
*  Current insurance carrier: *  How Long: yrs
    Policy Expires?
    Plan Type:

Applicant Information

    Name of Business
    (if applicable)
    Number of
    Number of
    Single Employees:
    Number of Couples:
    Number of
    Family Employees:
    Number of
    Employee plus child:
*  Deductible:
Additional Information:
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