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Business Details
Today's Date: *
Business Owner or Manager: *
Email Address: *
Business Name: *
Phone Number: *
Street Address *
City: *   State: *   Zip: *

Total Number of Employees
Total Number of All Employees: *  Out of Area : *
Those Working Total 17.5 or More Hrs/Wk: *  

Insurance Information
Current Medical Insurance Company: *
Anniversary Date of Current Insurance: *
Insurance Probationary Period For New Employees: From 1st of the Month Following:
Total No. of Employees Covered by Current Group Health Plan: *
Do You Have Dental Insurance? Yes No
:Would You Like a Dental Proposal? (Ad Now?) Yes No
Census of Your Employees

 Fill in the Area Below For Each Person To Be Covered:
Last Name of Employee: Gender:
(Check One)		 Birth Mo/Yr:
(Enter MM/YYYY)		 Insurance will Be For:
(Enter Employee, Employee & Spouse, Family, Employee & Children, or Not Enrolling)		 Enter
No. of
Children:		 Enrollment Status:
(Enter Full, Part, COBRA, or Not Elgibile)
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