Request for PWA COBRA/RELiance and HIPAA Services

Thank you for your interest in PWA Insurance Services' COBRA/RELiance and HIPAA Services. 

In order for us to respond to your inquiry, please complete the form below. Once it is completed press the "submit" button.  We will contact you as soon as possible.

You may also call Bree Wallace at 916.631.7887 for more information.

Contact Information
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Client Name
Contact Name
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City
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Please answer the following questions. The answers given will help determine your proposed contract verbiage and level of administration needed. Thank you.
Number of Total EE’s:
Number of Active EE’s:
Total #of Active Group plans (medical, dental, vision):
Current Benefits	Carrier Name
Medical
Dental
Vision
HSA, HRA, Sect. 125, etc.
Who is administering your Company’s COBRA/HIPAA currently?	Choose One In-House TPA None
If TPA, which carrier?
Monthly rate:

2377 Gold Meadow Way, Suite 250
Gold River, CA 95670
Ph: 916.631.7887
Toll Free: 888.778.0771
Fax: 916.631.6880
Email

A division of MFG Retirement Systems Inc.
California Insurance License #OB89320

Securities offered through Conny K. Saab, Registered Representative, ePLANNING Securities, Inc., Member NASD/SIPC

Investment Advisory Services offered through ePLANNING Advisors, Inc., A Registered Investment Advisor