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Employee Benefits

Group Census Worksheet

For employers inside the U.S., currently available in MD, DC, VA only.

To Request a Group Quotation please start by completing the following form.
If you prefer to call or fax us, you may use this form as a guide to the kinds of
information we will need to process your quote. When you hit the SUBMIT button,
your quote request will be delivered via email to our customer service department
for immediate attention. We may need to call you for additional information.
Please note that this is not an interactive quote site. We will contact you after
reviewing your information
. Thank you!

Company Name:

 

Your Name:

 

Address:

 

City:

 

State:

 

Zip:

 

Contact Person:

 

Contact Email:

 

Type of Business:

 

Number of Full-Time Emplyees:

 

Number of Part-Time Employees:

 

 

Employee Name
(Please note whether available for single, family, employee spouse or employee & children)

DOB

Sex

Single

Family
(Spouse & Children)

Employee & Spouse

Employee & Children
(please note # of children)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 Please provide coverage details about your current plan (PPO, POS, HMO,deductibles etc.)

 

 

Health Care Plan Provider:

 

Health Rates:

 

Single:

 

Parent/Child:

 

Family:

 

Employee/Spouse:

 

Comments:

 

 

 



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