Small Group Census
Business Name:
Phone:
Address:
Fax:
City:
email:
State:
Type of business:
Zip code:
Contact Person:
Current Plan Information
Insurance Company:
Premium:
Type of plan:
Chose one
PPO
HMO
POS
HSA
Deductible:
$250
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$4,500
$5,000
$10,000
Coinsurance:
N/A
100%
90%
85%
80%
75%
70%
60%
50%
Out of Pocket Maximum:
Sex
Age
Type Coverage
Zip
Known Conditions
1
N/A
M
F
E
ES
EC
EF
2
N/A
M
F
E
ES
EC
EF
3
N/A
M
F
E
ES
EC
EF
4
N/A
M
F
E
ES
EC
EF
5
N/A
M
F
E
ES
EC
EF
6
N/A
M
F
E
ES
EC
EF
7
N/A
M
F
E
ES
EC
EF
8
N/A
M
F
E
ES
EC
EF
9
N/A
M
F
E
ES
EC
EF
10
N/A
M
F
E
ES
EC
EF
11
N/A
M
F
E
ES
EC
EF
12
N/A
M
F
E
ES
EC
EF
13
N/A
M
F
E
ES
EC
EF
14
N/A
M
F
E
ES
EC
EF
15
N/A
M
F
E
ES
EC
EF
16
N/A
M
F
E
ES
EC
EF
17
N/A
M
F
E
ES
EC
EF
18
N/A
M
F
E
ES
EC
EF
19
N/A
M
F
E
ES
EC
EF
20
N/A
M
F
E
ES
EC
EF
Type of Coverage
E = Employee only
ES = Employee & Spouse
EC = Employee & Children
EF = Family
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Copyright 2001 Larry Fisackerly. http://www.einsuranceplace.com a Texas company offering health insurance Texas and health insurance free quotes for individual, maternity, group, and medicare supplement health policies. All rights reserved.
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