Company Information Company Name Contact Name Address City State Zip Code Email Telephone Number Fax Number Proposed Effective Date Current Carrier Current Renewal Date Company Structure Sole Proprietor Partnership Corporation LLC Other Type of Business More than one location? YesNo Number of Full Time Employee's (30+ hours/week) Employer Contribution for Employee Employer Contribution for Dependents Employees Living Out of State? YesNo Are you interested in other products? Life Dental LTD Please fill out the Group Census Form and email to lauren@shophealthinsurancenow.com OR upload the completed form:
