INSURANCE NOW Confidential Employee Census
SOURCE:		DATE:
GROUP NAME:		PHONE:
TYPE OF BUSINESS:		MAIN CONTACT:
CITY:	ZIP:	COUNTY:
TOTAL EMPLOYEES:		# COVERED 1099'S:
CURRENT CARRIER:		COST:

#	EMPLOYEE NAME	SEX	AGE	SPOUSE AGE	COVERAGE DESIRED*	SMOKER E OR SP
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

To add additional employees: click here

Coverage: E-employee only ES-spouse EC-children (also give # of children to be covered) F-family (also give # of chldren to be covered)
Mark key employees (officers and owners) with an "*" if they need 24 hour coverage.

Please complete and fax this form to Insurance Now at: (770) 396-4318 or email to: holly@insurance-now.com or
mail it to: Insurance Now, 5 Dunwoody Park South, Suite 113, Atlanta, GA 30338
For Questions, please call us at (770) 396-9517 or toll-free at (877) 711-8376