Group Health Insurance Census Form

This Group Health Insurance Census Form may be used for groups of 25 or less employees. For groups larger than 25 employees, complete the 26+ Census Form and fax to 252-727-5400.

To provide fast service, where possible we will send your Quote via Email. In order to deliver the most competitive pricing we may need to contact you via telephone. Only one of our representatives will call to verify your quote or get any additional information needed.

Company Name: Address: (Line 1) (Line 2) County: City: State: -- AK AL AR AZ CA CO DC DE FL GA IA IL IN KS LA MD MI MN MO MS MT NC NE NJ NM NV NY OH OK OR PA RI SC SD TN TX VA WA WI WV WY Zip Code:     Nature of Business: Contact Name: Email: Telephone: (with Area Code) Current Carrier:
Total Number of Employees (Total employed by company) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Number of Eligible Employees (employed 30 hrs per week or more) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Desired Effective Date of Coverage	Sep 15thOct 1st Oct 15th Nov 1st Nov 15th
Select the Deductible Amount	Any $250 or less $250 - $500 $500 - $1000 $1000 - $2500 $2500 or above
Select the Coinsurance Amount	Any 60 / 40 70 / 30 80 / 20 100%
Employer Contribution for Employee	50% 60% 70% 80% 90% 100%
Employer Contribution for Dependents	0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
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