Group Census Form
We only quote A+ and A Rated Companies!
Company Name
Contact Name
Address
Email
City
State
Zip
Tel #
Proposed Effective Date
Current Carrier
Current Renewal Date
Company Structure
Sole Proprietor
Corporation LLC
Partnership
Other
Type of Business
More than one location?
Yes
No
How many Full Time Employee's (30+ hours per week)
How many weeks payroll?
# of Cobra's ?
% of costs to be paid by Employer:
% of costs to be paid for Dependents by Employer:
Types of Employees
All
Management
Hourly
Salary
Non-Union
Employees Living out of State:
Yes
No
Industry SIC code:
Are you interested in other products:
Life
Group Dental
Group Vision
Telemedicine
Short Term Disability
Long Term Disability
Workers Compensation
Commercial Insurance
Payroll deduction plans
Sec 125 Cafeteria Plan
Known Medical Conditions (please describe)
Number of Employees
We will need a copy of current census - will you be able to provide that to us ?
Yes
No
Please download your census here:
Submit Census
Should be Empty: