Download PDFGroup Health Insurance Census (Existing Insurance in place)Your Email* Company Name*Phone*Your Company Specializes in*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* In order to get an accurate comparison, please provide the following informationCurrent 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* Yes NoAmount of Life Cover Needed*When do you renew your Health Insurance with your current Carrier*EmployeesName of EmployeeM/FE.E. Date of BirthEmployee AgeSpouse's Date of Birth (if applicable)**Spouse's AgeNo. of children (ages not important)Residence Zip Code **Notes: If no spouse - indicate single or divorced - only if there are dependents E.E. = Employee If spouse has his/her own insurance, leave spouse details out.CAPTCHA
