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Contact Name:	Mr. Ms. Mrs.
Company:
Address:
City, State, Zip:	,
Phone Number:	ext.
Fax Number:
E-Mail Address:
Type of Business:
Number of Employees:
Plan Type:	Select HMO PPO MSA All of the Above
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) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 2) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 3) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 4) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 5) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 6) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 7) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 8) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 9) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 10) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 11) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 12) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 13) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 14) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 15) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 16) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 17) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 18) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 19) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 20) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 21) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 22) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 23) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 24) Male Female Employee Only Employee + Spouse Employee + Children Family Y N 25) Male Female Employee Only Employee + Spouse Employee + Children Family Y N

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