Harmony Health Insurance Services
Susan Fujimoto, Authorized Agent
quote@harmonyhealthinsurance.com
Phone: (310) 913-5696
eFax (310) 496-2777
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Company/Group Name *
Contact Name *
Email *
Address *
Phone number *
What products are you interested in? *
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Number of Employees (Including Owner and W2 Employees) *
Owner Name & Date of Birth (include dependents if applicable)    *
Employee #1 -  Name & Date of Birth (include dependents if applicable) 
Employee #2 -  Name & Date of Birth (include dependents if applicable) 
Employee #3 -  Name & Date of Birth (include dependents if applicable) 
Employee #4 + 
Please include all other employee and dependent information
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