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Request for Group Census
to review your Group Benefit Package

Name of Business
City # of Full time
Employees
County # of Part time
Employees
Phone # Present Carrier
Fax # Renewal Date
E-Mail Address Sic code
Type of business

Check the benefits that you would like us to include in your quote:

Medical Dental
Long Term Disability Group Life Insurance
Prescription Drug Cards Well Baby Care
Maternity Full Coverage Workers Compensation
Full Takeover Required Additional Life Insurance
Vision Other
Medical Plans you would like to have:
Check all that apply   HMO PPO POS Indemnity Self-Insured

We represent over 170 leading Insurance Companies.

High priorities (Check appropriate boxes)
This will help us to focus on marketing the right co. and product:

Lower Current Premiums
Improve Current Benefits
Sec.125 Program/Cafeteria Plan
Show Partial Self-Insured Concepts

This will help us focus our attention on areas that concern you:

Present concerns or dislikes
Premiums Excellent Pleased Concerned Displeased
Benefits Excellent Pleased Concerned Displeased
List of Providers Excellent Pleased Concerned Displeased
Claims Service Excellent Pleased Concerned Displeased
Agent/Broker Service Excellent Pleased Concerned Displeased
Other: Excellent Pleased Concerned Displeased
Other: Excellent Pleased Concerned Displeased
Name of Current Broker

 

Employee Name
(Optional)		 Annual Salary
(Optional for
disability)		 Age/DOB Sex Dependent
Status		 Home
Zip Code		 Preferable
Physician of
Choice(Optional)

For more than 11 employees, please contact us for complete analysis.