310-698-0333  Fax: 310-698-0335
Public Insurance License # OE36304

E-Mail Click Here

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Atalla-Badir
Insurance Agency Inc

Group & Individual Health Insurance

Company Name
Address
City
State
Zip
Phone
Fax
Group Contact Person
Contact E-mail
Current Ins. Co.
1) Name
Age
Spouse
Hm Zip
Wkrs' Comp.
2) Name
Age
Spouse
Hm Zip
Wkrs' Comp.
3) Name
Age
Spouse
Hm Zip
Wkrs' Comp.
4) Name
Age
Spouse
Hm Zip
Wkrs' Comp.
Bold = Required field
Type of Business

_______________Please Select_______________

 Group Health Insurance or Individual Health Insurance

_____________Group Health Insurance_____________

Employee Information

For additional employees, please fax information to 310-698-0335.

Please complete the following
form and click Submit.

You can request a quote
and get a 24 hour response.

Click Here for Direct Link to
Tonik/Blue Cross

For all other Insurace Carriers
please fill out this form.

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Public  Insurance Agency Inc.
3621 N. Sepulveda Blvd. #1, Manhattan Beach, CA 90266

Phone (310) 698-0333   Fax (310) 698-0335
 All information you provide is solely used for the purpose of providing you with quotes. We will not sell, give or transfer
your personal information to any person or entity other than the insurance companies, agents and representatives we work with.

Hours: Monday - Friday 9:00am-5:00pm, Saturdays by Apt.                                                 E-Mail Click Here
First Name
M.I.
Last Name
Address 
City
State
Zip
E-mail Address
Phone
Age
Current Insuarance Co.
Any pre-existing condition:
Bold = Required field

_____________Individual Health Insurance____________

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