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Group Census Form
 









 

 

 

 

 

 

  

 

Contact Information
Group Name:
Contact Name:
Address:
City:
State:   Zip:
Business Phone: Fax Number:
E-mail Address:
Business Specialty:

Group Census
Please list all full-time employees (30+ hrs) taking coverage and waiving coverage.
Employee Name
(Last, First)		 Gender DOB
(mm-dd-yy)		 Smoker Coverage Spouse
DOB		 No. of
Children*		 Zip Code
(emp's residing
out of state)
* Number of Children (under 18 and full-time students age 18-25)

Current Plan Design
Current Plan Type: Traditional HMO PPO Point of Service
List other carriers used during the past four (4) years from current to past carriers. If none please type "none".
Carrier From
(mm-yy)		 To
(mm-yy)		 Reason Cancelled Monthly Premium
Current: $
 
 
 
Current Benefits Included:      
Maternity:  
Dental:  
Prescription Drug:  
Preventive Care:  
Vision Care:  


Please click the "Submit Quote" button to send your quote request.

This is a request for quotation only. No coverage is in effect until bound by an insurance carrier.


 

 

    
 
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The Zutz Group is licensed to provide Property and Casualty Insurance in all states except AK and HI.