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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Group Health Insurance Census (Existing Insurance in place)

Illinois Office

Missouri Office

Group Health Insurance Census (Existing Insurance in place)

Illinois Office

Missouri Office

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