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Small Group Census Data Requested Effective Date:
   
Employer Name :
Street Address : 
 
City :  
State :
Zip Code:
Country:
Telephone :
Fax :
Contact : Nature of Business:
Current Carrier: Renewal Date: Eligible Employees:
  Employees Enrolling: Current Plan Design: PPO Open Access POS
  Employer contribution %: Retirees: Plan Deductible:
  Coinsurance: Stop Loss: Office Co-pay:
  Hosp Co-pay: Rx Card:
Alternate Plan Design PPO Open Access POS HMO
  Plan Deductible: Coinsurance: Stop Loss:
  Office Co-pay: Hosp Co-pay: Rx Card:
Optional Benefits: Life & AD&D Amount or times salary
  Dental Deductible, Coinsurance, Plan Maximum
  Short Term Disability Long Term Disability
  401(k) Long Term Care
   
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Employee Name Date of Birth Sex Enrollment Status * Employee Zip Code Employee State Employee Occupation** Employee Salary
 

 * Please use the following Enrollment Status Codes

  • SGL = Single Employee
  • H&W = Employee & Spouse
  • P&C = Employee & Child(ren)
  • FAM = Family
  • Waiver = No Benefits
    (Note any employees who are on COBRA /NJ Continuation)
For Medical Quotes Include:
Current Billing Statement
Current Benefit Booklet
Renewal Data
For 401k Quotes
Plan Document
Plan Summary
5500 Form

** Required information for LTD/STD and multiple of salary Life coverage only