Group Health Census 1 Business Info2 Benefits Info3 Employee Info Business Name*Business Type*Select TypeSole ProprietorPartnershipCorporation / LLCOtherPrimary Contact Name* First Last Email* Phone*Business Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Benefits Requested* Health Dental Vision Life Short Term Disability Long Term Disability Auto & Home Discount Other Proposed Effective Date* Date Format: MM slash DD slash YYYY Number of Active Employees*1234567891011121314151617181920212223242525+Current Group Health Carrier:*SelectNONEAetnaAllied NationalATA AmericaAnthem BCBSBlue Cross Blue Shield Kansas CityCignaHumanaThe IHC GroupStarmarkUnited HealthcareOtherRenewal Date* Date Format: MM slash DD slash YYYY Upload a copy of current benefits (If Available) Drop files here or Employee CensusWould you like to add basic employee info now?*YesNoTo provide a legitimate comparison we will need additional employee details on an employee censusEmployee(s) Name Date of Birth Coverage Option Actions Edit Delete There are no Employees. Add Employee Maximum number of employees reached.
