Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio  
Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio Anthem Blue Cross Blue Shield Of Ohio  
 
 
 
EMPLOYEE CENSUS
 
Company: * Contact: *
Address: City: *
State: * Zip Code: *
Phone: * Fax: *
Type of Business: * SIC Code: *
No. of FTP Employees: *
Email: *
 
  Name Gender Age Spouse Age No.of Children Type of
Coverage		 Health Conditions
and Treatments
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
 
Please answer the following questions so that we can make an accurate comparison:
 
1. Who is your current insurance company?
2. What are your current premiums?
3. What deductible would you like quotes for? ($250 -$5000)
4. What effective date would you like?
5. Are you interested in Dental or Vision coverage?
6. What type of plan are you interested in? (PPO, HSA, etc)
 
Types of Coverage Codes:
 
EE= Employee Only EC= Employee & Child W= Waiving
ES= Employee & Spouse F= Family L= Life Only
To fax in this form, please print this PDF document and fax to us at (317) 803-4222.
 
 
Copyright © Nefouse & Associates, Inc. All Rights Reserved. Benefits are subject to change. Description of insurance plans does not guarantee coverage.