Company Group Census Please enable JavaScript in your browser to complete this form.Company InformationCompany Name *Requested Plan Effective DateEmployee InformationDoes your group already have a census?YesNoIf you already have a Company Group Census, please upload it here. Click or drag files to this area to upload. You can upload up to 3 files. EmployeesPlease provide the employee's full name, date of birth, gender, whether they are a smoker, and whether they are single (S) or family (F). If there are multiple entries, list each one on a separate line (e.g., Name: John Doe / DOB: March 4, 1992 / Smoker: No/ F). If you do not have a census, the more information you can provide on number of employees and their ages, the better idea we can give you of approximate costs. Plan StructureDo you currently provide health benefits to your employees? If so, what is your current plan and what does the company pay vs. what the employees pay?Is there anything you would like us to know about your situation or your objectives?Submit to Receive a Quote