Employee Benefits Census

You really can save money & get the right coverage too!
If you have more than one site, call us or complete an application for each site....whatever works best for you.
Business Name
Mailing Address
City/ST/ZIP
Site Address
Your Name
Telephone Number
Fax Number
e-mail Address
Ownership
Year Business Began

Check the boxes that best describe your operations

 Day Care
Center

 Service
Agency

 Infant
Center

 Residential
Care
Head
Start

 Camps

 Enrichment
Center

 Computer
Lab
Grade
School

 Counseling
Center

 Club

 Teen
Center
Empl
#		 Employee
Age		   Home
Zip Code		 Health Dental

Life
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
Do you have a group health plan now?
Do you have any COBRA participants
Do you want a

reportcard.gif (2142 bytes)