Your Name
Company Name
Industry Description
Street Address
City
State/Province
Zip/Postal Code
Work Phone
FAX
E-mail
URL

How would you rate your current health insurance plan?

bad poor average fair good

How many eligible employees would be considered for coverage?

Employee Census

	Name of Employee		Sex	Age	Coverage
1)			M F		Employee Employee + Spouse Employee + Children Family
2)			M F		Employee Employee + Spouse Employee + Children Family
3)			M F		Employee Employee + Spouse Employee + Children Family
4)			M F		Employee Employee + Spouse Employee + Children Family
5)			M F		Employee Employee + Spouse Employee + Children Family
6)			M F		Employee Employee + Spouse Employee + Children Family
7)			M F		Employee Employee + Spouse Employee + Children Family
8)			M F		Employee Employee + Spouse Employee + Children Family
9)			M F		Employee Employee + Spouse Employee + Children Family
10)			M F		Employee Employee + Spouse Employee + Children Family

11)

M F

Employee Employee + Spouse Employee + Children Family

12)

M F

Employee Employee + Spouse Employee + Children Family

13)

M F

Employee Employee + Spouse Employee + Children Family

14)

M F

Employee Employee + Spouse Employee + Children Family

15)

M F

Employee Employee + Spouse Employee + Children Family

Larger than 15 Employees?

Note> If you have more than 10 employees please download this form> Census

Please provide the name of your current carrier if any:

Insurance Carrier

Please include any additional information such as health conditions, unique situations and needs. This will aid us in making proper recommendations up front for your company. Be sure to indicate if you are Salt Lake City Chamber Member for discounts!