*Employer Name		*Contact Person
*Nature_ of Business		Referred by
*Address1		SIC Code
Address2
*City
*State		*ZIP
*Telephone
FAX
EMail

Current Plan Information

Current Insurance Co. Renewal Date             Jan Feb Mar Aprl May June July Aug Sep Oct Nov Dec Current Benefits:     Dr. Visits   $                    Hospital   $                    Emergency Room   $               Prescription  $ Current Premium:     Individual   $                      Family   $                             Employee & 1 Dependent (Either spouse or 1 child)  $ Total # of Full-time Employees (30+ hours / including owners) *  ## Number of Full-time Employees waiving coverage * Total # of employees to be covered. (List employees on form below) * ## Coverage can be waived for the following reasons:  Employee is age 65 of older and covered by Medicare OR Is covered by spouse's employer plan OR  Resides in area outside the network service area OR Is on COBRA OR  MA Health

Please check any additional benefits you are interested in. 

** Please note: Disability quotations require salaries of each employee.

Dental             Short Term Disability**                      Life

  Long Term Disability**                                                Long Term Care

Employee Census Sheet

* I - Individual  D - Dependent (Spouse or Child)    F - Family

Employee Name	Gender	D.O.B. MM/DD/YY	Zip Code	I / D / F*	Salary
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F

Comments

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