Group Census Form

Company Name:
Contact Name:
Address:
Email:
City:
State:
Zip:
Phone:
Fax:
   
Proposed Effective Date:
Current Carrier:
Type of Business:
# of Cobra's:
Industry SIC Code:
   
Group Term Life Insurance (Amount):
Would you like Dental Insurance:
   

Known Medical Conditions: (please describe)

Number of Employees: