Group Insurance Census Form

Contact Information

Company Name:
Contact Person:
Address:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email Address:

Employee Information

Note: If you need a quote for more than 20 employees, please send an Excel spreadsheet with the information requested below to info@reeddowney.com.

	Gender	Age	Spouse	Children	Zip Code
Employee #1			Spouse

Employee #2			Spouse

Employee #3			Spouse

Employee #4			Spouse

Employee #5			Spouse

Employee #6			Spouse

Employee #7			Spouse

Employee #8			Spouse

Employee #9			Spouse

Employee #10			Spouse

Employee #11			Spouse

Employee #10			Spouse

Employee #13			Spouse

Employee #14			Spouse

Employee #15			Spouse

Employee #16			Spouse

Employee #17			Spouse

Employee #18			Spouse

Employee #19			Spouse

Employee #20			Spouse

Company Insurance Details

Current Carrier:
Plan Renewal Date:
Current Deductible:
Plan Design:
Doctor office visit Co-pay Amount:
Prescription Benefit:
Max. Out of Pocket
Group Term Life Amount:
Do You offer or want to offer:
	Dental
	Short Term Disability
	Long Term Disability
	Cafeteria Plan
	Long Term Care
	Voluntary Life
	Cancer or Catastrophic Illness Plans