Census for Group Accident Quote
COMPANY
Name:
City:
Zip:
Industry:
(Please be specific)
AGENT OF RECORD
Phone:
Email:
Fax:
PLAN DESIGN
Per Accident
Deductible
$250 $500 $1000 $2500 $10,000 $25,000 $20,000
CSL
$ Benefit
100,000 150,000 200,000 250,000 300,000 500,000 750,000 1,000,000
Benefit Period
52 weeks 104 weeks 156 weeks other
Elimination
Period:
14 days 30 days 7/28 days
EMPLOYEE CENSUS
Number of Employees
Occupational
Code
Monthly Payroll $
Job Description
1
2
3
4
5
6
7
8
9
10
Total Employees
Total Payroll
Current Accident or Comp Premium $
Current Insurance Company
Total Claims Filed (2 Years) $
Comments or Questions: (Please include any pre-existing conditions and medications you are aware of.)
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