See Change Health Insurance Census

 


 

Health Insurance Census

Helping Businesses Find Affordable Health Insurance

Group Census Form
 
Company Name:
Contact Name:
Address:
Email:
City:
State:
Zip:
Tel#:
Fax#:
   
Proposed Effective Date:
Current Carrier:
Type of Business:
# of Cobra's:
Industry SIC Code:
   
Group Term Life Insurance (Amount ):
Would you like Dental Insurance?: Yes  No
Known Medical Conditions: (please describe)
Number of Employees - click here or press Tab to continue
EE#  EE Name M/F  Age/DOB  Enrollment Status Zip #COBRA'S
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   SUBMIT