Survey

MID- ATLANTIC MINISTERS FOR GROUP HEALTH INSURANCE CENSUS
1) Are you a Minister/ Staff Member interested in group health insurance for your family?
Email
example@example.com
2) Minister/ Staff Member

First Name Last Name
Minister/ Staff Member DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Smoking or Non-Smoking
3) Spouse

First NameLast Name
Spouse's DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Smoking or Non-Smoking
State and zip code of where you live

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5) Does the Minister/Staff Member need coverage?
6) Does the Spouse need coverage?
7) Does any children need coverage?
Number of female dependents
Ages
Number of male dependents
Ages
Comments
NOTICE: Please note that this is a census report only and it does not automatically create the approval of group health insurance. We will keep Bro. Rupert updated with the progress. Thank you for your cooperation and assistance.
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MID- ATLANTIC MINISTERS FOR GROUP HEALTH INSURANCE CENSUS