Small Group census form Fill Your Information Company Name* Contact Name* Address Email* City* State* Zip* Tel* Fax Proposed Effective Date Current Carrier Current Renewal Date Type of Business More than one location? YESNO Number of Full Time Employee's How many weeks payroll? # of Cobra's % of costs to be paid by Employer Types of Employees to be quoted AllManagementHourlySalaryNon-Union Employees Living Out of State YESNO Industry SIC Code Are you interested in other products? LifeDentalLTD Number of Employees Known Medical Conditions: (please describe) Δ
