Census Form

For your convenience, you may download our census form, complete and return to us by fax or email.

Fax No.:  (818) 881-1810
Email:  quotes@qsrinsurance.com

Please submit the following form and we will contact you soon to complete your quote.

Name: (required)

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Phone:

Name of Company:

Company Address:

Company City/State/Zip:

Number of Eligible Employees:

What Group coverages are you interested in?

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Disclaimer:  The material and information on this website has been prepared for informational purposes only, and is not intended to provide, and should not be relied on for, tax, legal or accounting advice.  For your convenience we have provided links to third party websites you may find useful.  Note we are not affiliated with these websites nor do we guaranty the availability or accuracy of the information contained in the linked sites.