USHealthPlans.com

Employer Sponsered Health Plans

 

Please fill out this form, and USHealthPlans.com will send you more information within two business days.

Contact Name:
 
Company:
Address:
City, State, Zip:
,
Phone Number:
ext.
Fax Number:
E-Mail Address:
Type of Business:
Number of Employees:
Plan Type:
Deductible Amount :
Requested Effective Date:
Would you like Dental or Life Quotes?
Prescription Drug Card: Yes No
Maternity: Yes No
Additional Comments :
Please fill out this census form so that we can better assist you.
Employee Name: Birthdate or Age: Gender: Dependent Status: # of Children Smoker
1)
Y N
2)
Y N
3)
Y N
4)
Y N
5)
Y N
6)
Y N
7)
Y N
8)
Y N
9)
Y N
10)
Y N
11)
Y N
12)
Y N
13)
Y N
14)
Y N
15)
Y N
16)
Y N
17)
Y N
18)
Y N
19)
Y N
20)
Y N
21)
Y N
22)
Y N
23)
Y N
24)
Y N
25)
Y N

Thank you for expressing an interest in our health insurance solutions!