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Request for Group Census Name of Business   City                      # of Full time Employees  County                 # of Part time Employees Phone #               Present Carrier                Fax #                   Renewal Date                 E Mail Address     Sic code                        Type of business   Check the benefits that you would like us to include in your quote Medical                        Dental                          Long Term Disability      Group Life Insurance      Prescription Drug Cards Well Baby Care             Maternity Full Coverage  Workers Compensation  Full Takeover Required   Additional Life Insurance Vision                           Other                            Medical Plans you would like to have: Check all that apply  HMO  PPO  POS    Indemnity  Self-Insured We represent leading Insurance Companies. High priorities (Check appropriate boxes) This will help us to focus on marketing the right co. and product: Lower Current Premiums  Improve Current Benefits  Sec.125 Program/Cafeteria Plan      Show Partial Self-Insured Concepts This will help us focus our attention on areas that concern you: Employee Name (Optional) Annual Salary (Optional for disability) Age/ DOB Sex Dependent Status Home Zip Code Preferable Physician of Choice (Optional) Male Female Employee Only Employee & Spouse Employee & children Family Male Female Employee Only Employee & Spouse Employee & children Family Male Female Employee Only Employee & Spouse Employee & children Family Male Female Employee Only Employee & Spouse Employee & children Family Male Female Employee Only Employee & Spouse Employee & children Family Male Female Employee Only Employee & Spouse Employee & children Family Male Female Employee Only Employee & Spouse Employee & children Family Male Female Employee Only Employee & Spouse Employee & children Family Male Female Employee Only Employee & Spouse Employee & children Family Male Female Employee Only Employee & Spouse Employee & children Family For more than 10 employees, please contact us for complete analysis.