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Group Census Form
Company Name
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Contact Name:
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Address:
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Email:
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City:
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State:
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Zip:
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Tel#:
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Fax#:
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Proposed Effective Date:
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Current Carrier:
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Current Renewal Date:
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Company Structure:

Type of Business:
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Number of Full Time Employee's (30+ hours/ week)
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How many weeks payroll?
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Number of Cobra's:
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% of costs to be paid by Employer:
% of Employee Costs
% of Dependent Costs
Industry SIC Code:
Are you interested in other products?
Known Medical Conditions: (please describe)
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Number of Employees
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