Group Health Census Form - Page 1
*
indicates required
*
Contact Person:
*
Job Title :
*
Email Address:
*
Company Name:
Company Address:
*
City:
State:
*
Zip:
*
Company Phone Number:
Alt. Phone Number :
*
Type of Business:
*
SIC Code
:
Current Plan Underwriter:
Current Premium:
Coverage Types:
(check all that apply)
Health
Life
Dental
Optical
Long Term Disability
Short Term Disability
*
Coverage Start Date:
Please Select
1 January
1 February
1 March
1 April
1 May
1 June
1 July
1 August
1 September
1 October
1 November
1 December
*
Number of Employees:
(Minimum 2)
Additional Comments:
Caution: Please check that the above
information is correct before proceeding.