Group Health Census
When you complete the form click the "Submit Census" button on the bottom of the page.
Company Name
Contact Person
First Name
Last Name
Company Zip Code
Preferred Quote Delivery Method
Call
Email
Fax
Phone Number
-
Area Code
Phone Number
E-mail quotes to
Fax quotes to
-
Area Code
Phone Number
Current Plan Information
Current Carrier
Please Select
Aetna
Capital BlueCross
Geisinger Health Plan
HealthAmerica/HealthAssurance
Highmark Blue Shield
Inter-County/Gettysburg Health
Teachers Protective Mutual
United Health Care
Other
Current Deductible
Please Select
$0
$250
$500
$750
$1000
$1250
$1500
$2000
> $2000
More than One Benefit Plan Offered
No
Yes
Requests or Comments
Employee Information Section
Please include only the employees that are on your health insurance plan.
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Name
Age or Date of Birth
Coverage Tier
Please Select
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family
Home Zip Code
Submit Census
Should be Empty: