Group Census Form
We only quote A+ and A Rated Companies!
Proposed Effective Date
Current Renewal Date
Type of Business
More than one location?
How many Full Time Employee's (30+ hours per week)
How many weeks payroll?
# of Cobra's ?
% of costs to be paid by Employer:
% of costs to be paid for Dependents by Employer:
Types of Employees
Employees Living out of State:
Industry SIC code:
Are you interested in other products:
Short Term Disability
Long Term Disability
Payroll deduction plans
Sec 125 Cafeteria Plan
Known Medical Conditions (please describe)
Number of Employees
We will need a copy of current census - will you be able to provide that to us ?
I will fax it to you at 972.852.9029
Please download your census here:
Should be Empty: