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Group Medical / Dental Census

To receive a FREE, no obligation quote for Group Medical and/or Group Dental Insurance,
please fill out and submit the following form. If you have any questions, you can call us at
Phone: 866-527-1910
206-922-2424
360-687-3002

Please complete ALL Information as accurately as possible.

You may also print this form and fax it to us.
Company Name:
Contact's Name:
E-Mail Address:
Type of Business:
Physical Address:
City:
State:
Zip/Postal Code:
County:
Phone:
Fax:

What type of insurance are you looking for?

Medical       Dental  Other: 

Current Medical Carrier: Indicate none if none.
Plan Type:
Current Dental Carrier: Indicate none if none.
Plan Type :
Deductible:
Co-Pay if Any:
Renewal Date:
Employer Pays: % of Employee Premium
Employer Pays: % of Dependents Premium
Intended Effective Date:

Do You Have Employees Covered Under
Collective Bargaining Agreements?
Number of employees to be covered
Is an MSA or Sec125 Plan Currently Available?
  Name (first name is fine)

Gender

Employee Date of Birth

Residence
Zip Code 

Type of Coverage

Spouse Age or Date of Birth

# of
Children

Children's Ages

1 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
2 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
3 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
4 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
5 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
6 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
7 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
8 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
9 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
10 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
11 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
12 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
13 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
14 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
15 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
16 Employee Name
 Gender
 Date of Birth Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
17 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
18 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
19 Employee Name
 Gender
 Date of Birth Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
20 Employee Name
 Gender
 Date of Birth
 Zip Code
 Select Type of Coverage
 Spouse Age
 #Children
  Ages
 

 
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