INSURANCE NOW Confidential Employee Census
#	EMPLOYEE NAME	SEX	AGE	SPOUSE AGE	COVERAGE DESIRED*	SMOKER E OR SP
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95

To add additional employees: click here

Coverage: E-employee only ES-spouse EC-children (also give # of children to be covered) F-family
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
mail it to: Insurance Now, 5 Dunwoody Park South, Suite 110, Atlanta, GA 30338
For Questions, please call us at (770) 396-9517 or toll-free at (877) 711-8376