Group Health Insurance Census (Existing Insurance in place)
Date: 12/10/2018
Company Name:  
Your Company Specializes in:    
City:   State:
In order to get an accurate comparison, please provide the following information
Current Health Insurance Carrier:   
Current Annual Deductible:  (e.g. $1000 - this is very important)  
Current Physician Office Copay:  (e.g. $20 per visit)    
Current Coinsurance %:  (e.g. 80%/20% plan)  
Current Monthly Premium:   
Dental Cover Needed:
Amount of Life Cover Needed:   
When do you renew your Health Insurance with your current Carrier:   
Name of Employee M/F E.E. Date of Birth Employee Age Spouse's Date of Birth
(if applicable)**
Spouse's Age No. of children
(ages not important)
Residence Zip Code
If no spouse - indicate single or divorced - only if there are dependents
E.E. = Employee
Assurance Brokers, LTD © 2017 | Privacy Policy