COMPANY INFORMATION

Company Name: Today's Date:
Address: City: State: Zip:
Phone Number: Fax Number:
Owner Name: Contact Person:
Nature of Business: Years in Business:

CURRENT PLAN INFORMATION

Current Health Carrier & Plan Name: Current Dental Carrier:
Office Visit Co-pay $ Deductible $ Rx $ Vision:  
Dental Annual Maximum Benefit? Renewal Date: Employer Contribution:
Rates:  Medical
           Employee $ Renewal $ E+Spouse $ Renewal $
           E+Children $ Renewal $ Family $ Renewal $
           Dental
           Employee $ Renewal $ E+Spouse $ Renewal $
           E+Children $ Renewal $ Family $ Renewal $

EMPLOYEE CENSUS INFORMATION

1.   Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title:

2.   Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title:

3.   Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title:

4.   Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title:

5.   Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title:

6.   Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title:

7.   Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title:

8.   Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title:

9.   Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title:

10. Employee Name: Date of Birth: Sex:
      Persons to be Covered: Spouse Date of Birth: Number of Children:
      Child(ren)'s Ages: Job Title: