Group health insurance

Group health insurance census

Want to offer health insurance to your crew? Carriers need a census before they can quote a group plan: each employee's date of birth, sex, home ZIP, and who they want covered. Fill it in below. It takes about 5 minutes for a crew of ten.

1. The business

Business name

Your first name

Your last name

Phone number

Business street address

City

State

ZIP code

2. The plan you want

Total number of employees

Eligible employees (work 30+ hours a week)

When should coverage start?

Usually the 1st of a month.

Do you offer group health insurance today?

How much of each employee's premium will the business pay?

Most carriers require the employer to pay at least 50% of the employee-only premium.

How much of dependents' premiums will the business pay?

3. Employee census

List every eligible employee, including anyone waiving coverage. Carriers price group health on age, sex, home ZIP and who is covered. Don't enter Social Security numbers or any medical information.

Employee 1

Name or initialsDate of birthSexHome ZIPCoverage

Employee 2

Name or initialsDate of birthSexHome ZIPCoverage

Employee 3

Name or initialsDate of birthSexHome ZIPCoverage

0 listed · 0 enrolling · 0 waiving

Anything else we should know?

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