Assurance Brokers Ltd | Group Health & Disability Insurance Census

Group Health Insurance Census

Date: 5/23/2013

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	YesNo
Must we quote Life Cover?	YesNo	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.