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GROUP INSURANCE QUESTIONNAIRE AND CENSUS FORM

Company Information
Company Name:   
Company Contact: Salutation: First: Last:
Type of Business:
Address:
City:  State:   Zip:
Telephone:  
Fax:   Email:    
Requested Effective Date:   
Are you interested in:


Dental:  
Vision:  
Group Life:  
Our approach is to become more intimate with your unique Group Health Insurance needs in order to address your concerns and streamline the bidding process. We appreciate your valuable time for answering each of the questions below and sincerely look forward to serving you and building a long-term relationship. Thank you.
  1. Please list your current carrier and plan design:
  2. Briefly explain any concerns or frustrations your group may be experiencing with your current carrier(s), insurance plan(s), brokerage firm or other:
  3. In designing your medical insurance plan please choose your preferences from the following options:
    Physician Co-Pay   Minimum  
    Maximum  
    Deductibles (single/family)   Minimum  
    Maximum  
    Employee Co-Insurance   Minimum  
    Maximum  
    (Please note that as a general rule, the higher the Co-Pays, Deductibles and Coinsurance's are the lower the premium will be, and the lower the Co-Pays, Deductibles and Coinsurance's are the higher the premium will be.)

Employee Information  
Employee Name: Salutation: First: Last:   
Gender:  
Date of Birth:  
Home ZIP Code:  
Smoker:  
Spouse:  
# of Children/Dependents:  
Coverage Type:  
Waiving Coverage:  



By clicking the submit button you are stating that you are supplying USFSB with accurate information to retrieve health insurance quotes for employees in your company and are not committing to purchase. This census accurately represents the employees eligible for health care benefits at this time.

This document is Strictly Confidential and its use is regulated by HIPPA guidelines.

©2011 Joseph R. Cardamone Agency. All rights reserved. 1-800-637-1800