Fields with * are required
 

Personal Information
* Full Name
* Address
City
State
Zip Code
* Phone
Fax
* Email
Best Time to Call

Company Information
Company's Name
Position
Current Insurance Carrier (state if none)
If any, Anniversary Date of Current Carrier
Total Number of Employees
Number of Employees to be Insured
Are premiums paid by your company for employee only or family, too?
Current rate coverage for Single
Current rate coverage for Husband & Wife
Current rate coverage for Single Parent & Child
Current rate coverage for Full Family
What type of plan do you want compared?
If you want an HMO or Dual Option Plan compared, choose from the following co-payments:
If you want an HMO or Dual Option Plan compared, do you want a prescription plan?
If you want Dual Option Plan compared, please choose from the following deductible:
If you want Dual Option Plan compared, please choose from the following co-insurances:
What do you like or dislike about your current plan?
Additional remarks or requests

Census
Company Name
Street
State
City
Zip Code

Employee Data
Employee No. Birth Date Gender Coverage
Employee 1
Employee 2
Employee 3
Employee 4
Employee 5
Employee 6
Employee 7
Employee 8
Employee 9
Employee 10
Employee 11
Employee 12
Employee 13
Employee 14
Employee 15
Employee 16
Employee 17
Employee 18
Employee 19
Employee 20
Employee 21
Employee 22
Employee 23
Employee 24
Employee 25