Group Health Insurance Census (Existing Insurance in place)

Your Email*
Company Name*
Phone*
Your Company Specializes in*
Address*
Street Address Address Line 2 City State ZIP Code
County*
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*
- Yes
- No
Amount of Life Cover Needed*
When do you renew your Health Insurance with your current Carrier*
Employees
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
**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.
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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