{e-forms}  
Group Health Insurance Census
Date: 4/23/2014
Company Name:  
Telephone:    
Your Company Specializes in:    
Address:    
City:   State: Zip:  
County:    
In order to get an accurate comparison, please provide the following information:
Annual Deductible to be considered:     (e.g. $500-$1000 or higher)
Acceptable Coinsurance %:   (e.g. 80%/20% plan)  
Do you want an Office Visit Copay?  (e.g. $20 - $30 per visit)    
Do you want a Prescription Drug Card?   
Must we quote Dental Coverage
Must we quote Life Cover? Amount of Life Cover Needed:
Name of Employee M/F E.E. Date of Birth Employee Age Spouse's Date of Birth
(if applicable)**
Spouse's Age No. of children
(ages not important)
Residence Zip Code
 
**Notes:
If no spouse - indicate single or divorced - only if there are dependents
E.E. = Employee
If spouse has his/her own insurance, leave spouse details out.
 
  
 
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