Group Census

Company Name *
Contact Name *
Address *
AddressAddress Line 2CityState / Province / RegionPostal / Zip CodeCountry
Email *
Phone *
FAX
Proposed Effective Date *
Current Carrier
Current Renewal Date
Company Structure *
Sole PropiertorPartnershipCorporation/LLCOther
Type of Business
More than one location?
YesNo
Number of Full-time employees (30+ hrs/week)
How many Weeks of payroll
Number of Cobras
% Employer costs
% Employee Costs
% Dependent Costs
Type of Employees to be quoted
Employees living out of state
YesNo
Industry SIC Code
Number of employees
Are you interested in other products?
LifeDentalLTD
Known medical conditions