*
Required Information
GROUP HEALTH INSURANCE
EMPLOYEE CENSUS DATA REQUEST
Simpson Insurance Services
P.O. Box 914, Turlock, CA 95381-0914
Phone Number: 209-664-0477 or 888-664-0477 (toll free)
Fax: 209-664-0492 or 888-664-0492 (toll free)
Dennis D. Simpson
Agent/Broker
LIC # 0B12958
www.simpsonins.com
IMPORTANT INFORMATION NEEDED TO PROVIDE A QUOTE
Group Name:
*
Address:
*
City:
*
Zip:
*
Number of Full Time Employees:
*
Current Insurance Company:
*
Percent of Costs to be Paid by Employer:
% Employee Cost
*
% Dependent Cost
*
Telephone No.:
*
Group Contact Person:
*
E-Mail Address:
*
Renewal Date:
*
Current Monthly Premium:
*
EMPLOYEE NAME
LAST
FIRST
SEX
(M/F)
DATE OF BIRTH
(MO/DAY/YEAR)
DEPENDENTS
X IF
# OF
SPOUSE
CHILDREN
X
IF ON
COBRA
HOME
ZIP
CODE
LIFE
AMOUNT
($)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Copyright © 2006 - 2012 Simpson Insurance Services.
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