Placer West Insurance Services

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Contact Information
*Your Name:
Your Spouse's Name:
*Home Address:
*City (California Only):
Driver Information
Name DOB DL# Tickets Accidents
Auto Information
Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Ann. Miles:
Primary Driver:
Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Bodily Injury
Property Damage:
Uninsured Motorist / Under-Insured Motorist:
Uninsured Motorist Property Damage:
Comprehensive Deductibles:
Collision Deductibles:
Towing Reimbursment:
Rental Reimbursment:

Federal Poverty Level (FPL) Chart

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HSA Contribution Limits

Please be aware of the 2016 annual HSA contribution limits listed below.

  • $3,350* - Maximum HSA Annual Contribution Limit (Self-only)
  • $6,650* - Maximum HSA Annual Contribution Limit (Family)
  • $1,000 - HSA Catch-up Contribution Limit
  • $1,300 - Minimum HDHP Annual Deductible (Self-only)
  • $2,600 - Minimum HDHP Annual Deductible (Family)
  • $6,450 - Maximum HDHP Annual Out-of-pocket (Self-only)
  • $12,900 - Maximum HDHP Annual Out-of-pocket (Family)
  • *For purposes of the full contribution rule an employee is treated as being eligible for the entire calendar year as long as he or she is eligible as of December 1 of that calendar year and continues eligibility throughout the following year. However, failure to maintain eligibility during the "testing period" will result in adverse tax consequences (including an additional excise tax). The testing period begins in December of the year in which the employee becomes eligible and ends the last day of December of the following year.

Words of Wisdom

“I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them.”
– Thomas Jefferson

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