Carrier's Choice Quote Request Form

Carrier's Choice familyTo obtain a quote please fill out the following census form. We may require some additional information such as:
1. Name of your current insurance Carrier
2. Summary of your current insurance plans
3. Most recent billing statement.

You may fax or email this additional information to:
FAX 714-546-4457 | EMAIL info@rsi-ins.com 

Quote Request Form

BENEFIT INFORMATION
Which type of Plan would you like a quote on?


GROUP INFORMATION
Anyone on COBRA?


Any 1099 Employees?


Do any employees live out of state?


CTA Membership Information
Are you currently a member of the California Trucking Association (CTA)?


Additional Coverages
Do you currently have DENTAL?


Do you currently have VISION?


Do you currently have LIFE?


Do you currently have DISABILITY?


If you selected NO on any of the above questions, please indicate which additional coverages you'd like to obtain




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