Exhibit 10.19

                          INVESTMENT SERVICES AGREEMENT

           THIS  AGREEMENT  is between  COMMERCIAL  CASUALTY  INSURANCE  COMPANY
(hereafter  "Company"),  and SIERRA HEALTH SERVICES,  Inc., a Nevada corporation
(hereafter "Investment Manager") and is effective as of January 1, 1999.

Whereas, Company is an insurance company with substantial investments; and

Whereas,  it would be beneficial for Company to obtain  investment  services set
forth  herein  subject  to the  review  and  ultimate  control  of its  Board of
Directors and its appropriate officers; and

Whereas,  Investment  Manager  can  supply  investment  services  to  Company as
described in this Agreement.

Now, therefore, the parties agree as follows:

1.                  INVESTMENT SERVICES

  (a)      Investment Manager shall furnish to Company  investment  services for
           the  Investment  Assets (as  hereinafter  defined) of  Company,  such
           services to include the following:

     1. to counsel and advise  Company and its Board of Directors in  connection
with  the  formulation  of  investment   programs  designed  to  accomplish  its
investment objectives; and

     2. to manage the Investment  Assets in accordance  with the laws applicable
to  Company  and  with  the  investment  policies,  objectives,  directions  and
guidelines established by the Board of Directors and officers of Company; and

     3. subject to other provisions of this Agreement  including but not limited
to  Section  1(c) of this  Agreement,  to have full  discretion  and  authority,
without prior  consultation or prior approval,  to buy, sell and otherwise trade
in  stocks,  bonds  and  other  securities  and take such  other  actions  which
Investment Manager shall deem requisite, appropriate or advisable.

           However,  Investment  Manager  shall  not  act  as  custodian  of the
Investment Assets.

  (b)      Investment  Manager  agrees that it will  maintain  adequate  records
           relating  to  the  furnishing  of  investment   services  under  this
           Agreement,  including  those  with  respect  to the  acquisition  and
           disposition of securities for Company.

  (c)      Investment  Manager agrees that the investment  services it furnishes
           will be in accordance with (1) Company's general investment policies,
           objectives and guidelines  established from time to time by its Board
           of  Directors  and (2) any  written  instructions  given by the Chief
           Executive  Officer or Chief  Financial  Officer of Company or persons
           designated by either of them in writing as such written  instructions
           shall be sent from time to time in writing  by Company to  Investment
           Manager.

  (d)      Investment Assets shall mean all bonds, stocks (exclusive of those of
           affiliates  and  subsidiaries),   short-term  investments  and  other
           invested assets (i) reportable as held by Company on Schedules B, BA,
           C and D in the  Investment  Reporting  System of Company and (ii) any
           other  assets of the  Company as  Investment  Manager and Company may
           from time to time agree.

2.                  PURCHASE AND SALE OF SECURITIES

     (a) Investment  Manager shall place all orders for the purchase and sale of
portfolio  securities for Company's  account with brokers or dealers selected by
Investment  Manager,  which may  include  a person  affiliated  with  Investment
Manager,  as the term affiliated person is defined in the Investment Company Act
of 1940  (hereafter  "Affiliate").  Investment  Manager  shall  seek to  execute
portfolio  transactions on terms which are advantageous to Company. In selecting
brokers or dealers to execute  transactions,  Investment  Manager  shall use its
best  efforts to obtain  the best  price and  execution  for  Company;  provided
however, with respect to an Affiliate,  Investment Manager shall comply with the
additional  requirements  set forth in paragraph 2 (b) below.  In evaluating the
terms  available  for  executing  particular  transactions  for  Company  and in
selecting brokers and dealers to execute such  transactions,  Investment Manager
may  consider,  in addition to  commission  cost,  the  financial  stability and
reputation and execution capability of brokers and dealers and the brokerage and
research services (as those terms are defined in Section 28(e) of the Securities
Exchange  Act of 1934,  as  amended)  provided  by brokers  and  dealers for the
account of  Company.  Subject to  paragraph  2(b) below,  Investment  Manager is
authorized  to pay a broker or dealer who provides  such  brokerage and research
services a commission for executing a Company portfolio  transaction which is in
excess of the amount of commission  another  broker or dealer would have charged
for effecting  that  transaction  if  Investment  Manager  determines  that such
commission  is reasonable in relation to the value of the brokerage and research
services  provided by such broker or dealer.  This  determination may be made in
terms of either a particular  transaction or the overall  responsibilities which
Investment  Manager  has  with  respect  to all of the  accounts  over  which it
exercises investment discretion.

     (b) Should an Affiliate engage in "agency cross  transactions"  (as defined
in Section  275.206(3)-2  of the  Investment  Advisers Act of 1940) in which the
Affiliate  acts as  broker  for both  sides  of a  transaction  and may  receive
commissions from, and have a potentially  conflicting  division of loyalties and
responsibilities  regarding,  both  parties,  or act as  principal  for  its own
account coming within the  provisions of Section 206 of the Investment  Advisers
Act of 1940,  Company for itself and its  subsidiaries  and affiliates which are
furnished  services  under this  Agreement  consent  to: (1) such  agency  cross
transactions  with such Affiliate,  and (2) transactions in which such Affiliate
is acting as principal for its own account,  so long as more favorable terms are
not practically available from another broker or seller as the case may be or so
long as the specific transaction is consented to by Company.  Company may revoke
this consent at any time by giving notice to Investment Manager. In transactions
other than agency cross transactions and principal transactions specified above,
Investment  Manager  may select an  Affiliate  as a broker or dealer to place or
execute  orders for the purchase or sale of  securities  pursuant to  Investment
Manager's authority under this Agreement, so long as the commission rate charged
by the  Affiliate  for such sale or  purchase  conforms to the  requirements  of
paragraph 2(a) above and is equal to or lower than that charged any of its other
customers for like sales or purchases.

     (c) Provided the  investment  objectives of this  Agreement are adhered to,
Company agrees that  Investment  Manager may aggregate sales and purchase orders
of Investment  Assets with similar  orders being made  simultaneously  for other
accounts managed by Investment  Manager, if in Investment  Manager's  reasonable
judgment such  aggregation  shall result in an overall  economic  benefit to the
Investment Assets taking into consideration the advantageous selling or purchase
price,  brokerage  commission and other expenses.  Company acknowledges that the
determination  of  such  economic  benefit  to  Company  by  Investment  Manager
represents   Investment  Manager's  evaluation  that  Company  is  benefited  by
relatively  better  purchase or sales  prices,  lower  commission  expenses  and
beneficial timing of transactions or a combination of these and other factors.


3.                  INVESTMENT FEES; EXPENSES

     (a) Company shall pay to Investment  Manager a fee equal to the  Investment
Manager's   allocated  costs  in  rendering  the  services  in  this  Agreement.
Allocation  shall  be made at the end of each  calendar  quarter  and  shall  be
derived from the Investment  Manager's  costs for such quarter  allocated on the
basis of the Fair Market Value of the  Investment  Assets for which services are
rendered under this Agreement to the Fair Market Value of all Investment  Assets
the Investment  Manager  managed or for which  services  similar to the services
under this Agreement were rendered during such Quarter. The fee shall be payable
in  arrears  30 days  after  the end of  each  calendar  quarter  in  which  the
Investment Services Agreement is in force.

  (b)      Fair Market Value on any date shall mean the fair market value of the
           Investment  Assets as reported in the Company or  Investment  Manager
           Investment  Reporting  System  for such date in  accordance  with the
           procedures  and rules for such  Reporting  System as  audited  by the
           auditors of Company.  Quarterly Ending Fair Market Value shall be the
           Fair Market Value on the last day of any calendar quarter.

  (c)      If services rendered hereunder shall commence on a day other than the
           first day of a calendar  quarter or terminate  other than on the last
           day of a  calendar  quarter,  the  above  fee  shall  be  fairly  and
           equitably prorated.

  (d)      Investment  Manager shall  furnish at its own expense all  facilities
           and administrative, accounting, clerical, statistical, correspondence
           and other  services  necessary  to  supply  the  investment  services
           required under this Agreement.  However, Company shall be responsible
           for the expenses of: (1)  brokerage  commissions,  issue and transfer
           taxes and other costs in connection with  securities  transactions to
           which Company is a party,  including any portion of such  commissions
           attributable to research and brokerage services; (2) taxes payable by
           Company  to  federal,  state and  other  governmental  agencies,  (3)
           primary record keeping and (4) custodial fees and expenses.

4.                  ULTIMATE CONTROL
                    ----------------

           All services  furnished  under this Agreement shall always be subject
           to the  direction  and  control  of the  Board of  Directors  and the
           authorized  Officers  of Company.  The Board shall act in  accordance
           with  Section  1200 of the  California  Insurance  Code to approve or
           ratify all the  investments  made in accordance  with this  Agreement
           and; if the Board acts not to approve any investment  made under this
           Agreement the  investment  shall be disposed of in as prompt a manner
           as reasonable. Notwithstanding any other provision of this Agreement,
           it is understood and agreed that Company reserves the right to direct
           any action to be taken hereunder on its behalf by Investment Manager.

5.                  NON-EXCLUSIVITY OF SERVICES

           The  services  of  Investment  Manager  to  be  provided  to  Company
           hereunder are not to be deemed exclusive and Investment Manager shall
           be free to  provide  similar  services  for its own  account  and the
           accounts  of  other  persons  provided  that  such  services  do  not
           materially interfere with its services hereunder.

6.                  LIABILITY; INDEMNIFICATION

           Investment  Manager  shall be liable to  Company  for any  liability,
           damages or expenses of Company arising out of the  negligence,  gross
           negligence or willful misfeasance of Investment Manager or any of its
           directors,  officers,  employees or Affiliates in providing  services
           under this Agreement.

7.                  TERMINATION

           This  Agreement  may be  terminated  by either  Company or Investment
           Manager  upon  notice to the other  party sent at least  thirty  days
           prior  to the  date  set for  termination  in such  notice;  provided
           further,  that in the event of a material breach of this Agreement by
           the other  party,  this  Agreement  may be  terminated  by Company or
           Investment Manager upon notice in writing sent at least 10 days prior
           to the date set for termination in such notice. Company shall pay any
           investment  fees due hereunder,  prorated to the date of termination,
           within ten days following the date of termination.

8.                  NOTICES

           Notices or other  writings  given or sent under or  pursuant  to this
           Agreement  shall be in  writing  and be deemed to have been  given or
           sent if delivered to the party at its address  listed below in person
           or by telex or telecopy or within 2 days of mailing if mailed postage
           prepaid to such address. The addresses of the parties are:

                    Commercial Casualty Insurance Company
                    2716 North Tenaya Way
                    Las Vegas, Nevada 89128
                    Attention: Chief Financial Officer
                    Telecopy :702 869 2379

                    Sierra Health Services, Inc.
                    2720 North Tenaya Way
                    Las Vegas, Nevada 89128
                    Attention: Chief Financial Officer
                    Telecopy :702 242 7534

           Each  party  may  change  its  address  by  giving  notice  as herein
required.

9.                  SOLE INSTRUMENT
                    ---------------

           This  instrument  constitutes  the  sole and  only  agreement  of the
           parties to it  relating  to its object and  correctly  sets forth the
           rights,  duties, and obligations of each party to the other as of its
           date. Any prior agreements, promises, negotiations or representations
           not expressly set forth in this Agreement are of no force or effect.

10.                 WAIVER OR MODIFICATION

           No waiver or modification of this Agreement shall be effective unless
           reduced to a written document signed by the party to be charged.

11.                 LAW OF CALIFORNIA


           This  Agreement  shall be  governed  by and  construed  in
           accordance  with  the  laws of the  State of California .

12.                 ASSIGNMENT AND DELEGATION

           No party to this  Agreement  shall have the right to sell,  transfer,
           delegate,  or  assign  this  Agreement,  its  rights or duties to any
           person,  firm,  or  corporation  at any time  during its term and any
           proposed  assignee  shall acquire no rights nor be able to assume any
           obligations  unless the  written  consent of the other  party to this
           Agreement is given before such assignment or delegation  takes place.
           Nevertheless,   Investment   Manager  may  appoint  other  investment
           advisers as sub advisers for the Investment Assets.

13.                 REPORTS AND RECORDS

           Investment  Manager  shall  provide to  Company  such oral or written
           reports as to its services  provided  under this Agreement as Company
           shall  reasonably  require  but  shall  report  investments  at least
           quarterly. All records maintained pursuant to this Agreement shall be
           deemed the property of Company and shall be subject to examination by
           Company  and  by  persons   authorized  by  it,  or  by  governmental
           authorities, at all times upon reasonable notice. Except as expressly
           authorized  in this  Agreement  or  directed  by the  other  party in
           writing,  Investment  Manager and Company shall keep confidential the
           records and other  information  obtained by reason of this  Agreement
           (including,  with respect to Company, the investment  information and
           recommendations   provided  to  it  by  Investment   Manager).   Upon
           termination of this Agreement, Investment Manager shall promptly upon
           demand  return to Company all such  records,  except that  Investment
           Manager may retain one copy in the files of its legal counsel.

14.        All references in this Agreement to "days" shall mean calendar not
           business days.





IN WITNESS  WHEREOF  the  parties  hereto  execute  this  Agreement  and make it
effective on the date set forth above.

                             COMMERCIAL CASUALTY INSURANCE COMPANY

                             by      s/John Okita

                                     J.  Okita
                                     Chief Financial Officer

                             SIERRA HEALTH SERVICES, INC.

                             by      s/Paul Palmer
                                     P. Palmer
                                     Chief Financial Officer