FORM INSTRUCTIONS GO TO FILE AND PRESS PRINT, COMPLETE THEN FAX TO (818) 906-2682__________(Home)

Please Fax to Pars Insurance Agency (818) 906-2682

Group Name_____________________Contact Name______________________________
Company Address__________________________________________________________
City_____________________________ State________ Zipcode__________
Phone Number____________________ Fax Number____________________
E-Mail__________________________

Number of employees ______
[ ] Dental ,
[ ] Employee Life Insurance ,
[ ] Dependent Life Insurance

Employee ShippinHome Zip ShippinAgehippinn Spouse Shippin No. of Children
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Please print as many copies as you need, complete and fax to (818) 906-2682, Thank you.