To ensure the most accurate quote, please complete all fields.
* Means required field.

After entering your census, one of our consultants will contact you to discuss some options.

EMPLOYER INFORMATION
Company Name:
Address:
City / State / ZIP:
Phone:	() -
Fax:	() -
Type of Industry:
* E-mail:
* No. of Employees:
Coverage Type	Select one Group Medical Group Long Term Disability Group Dental Group Life Pension Programs (401 K) Section 125 Cafeteria Plans Group Vision Care Programs Self-Funded Programs Employee Benefit Statements
* How did you hear about us?
EMPLOYEE INFORMATION
Employee 1 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 2 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 3 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 4 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 5 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 6 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 7 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 8 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 9 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 10 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 11 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 12 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 13 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 14 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 15 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 16 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 17 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 18 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 19 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
Employee 20 - Name:
Sex: Select one Male Female	Coverage Type: Select one Single Parent & Child(ren) Husband & Wife Full Family
Date of Birth / Home ZIP Code:
* Please correctly type in the following phrase to verify: Please type b.e.n.e.f.i.t.s. without the periods in the box to the right.