Group Health Insurance

Business Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Group Health Census Data (all full-time employees 25 hours+)

Owner : Owner, partner or officer of the company

Full-Time : Full Time employee who works 25 or more hours per week

Part-Time: Part Time empoloyee works less than 25 hours per week

Seasonal : Seasonal employee who works 120 days or fewer per year

Disabled : Totally Disabled employee

Cobra : Continuee under state or federal law

Union : Employee participating in an employee welfare arrangement established pursuant to a collective bargaining agreement.

Census details (Enrolling -all full-time employees 25 hours+)

Group Health Census Data (all full-time employees 25 hours+)

Plan Preferences

HMOPPOPOSEPO

COPAY

$10$15$20$30

PRESCRIPTION DRUGS

10/15/3515/25/50

Referred by: