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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 No Amount 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
