All information acquired by Dickson Health Insurance is kept strictly confidential and will not be shared with mailing lists or "spammers". NOTE: All fields marked with * are required. GROUP CENSUS SHEET * Name of Company: * Nature of Business: (complete description and SIC code) * Business Address: * County: * Zip Code: * Company Phone: * Company Fax: * Contact Person: * E-Mail Address: PRESENT INSURANCE PLAN INFORMATION * Name of Insurance Company: * Deductible: $ Monthly Premium Amount: Please check if your plan has: Doctor Visits Copay Drug Card Dental AD&D Life (Amount) Other CENSUS CODES: EE-Employees ES-Employee & Spouse EC-Employee & Child F-Family LO-Life Only Name Sex EE Date of Birth (xx-xx-xxxx) Spouse Date of Birth (xx-xx-xxxx) PLEASE CHECK IF APPLIES M F EE ES EC F # of Children LO Please note: If your company has more than 25 employees, please submit this form now, then return to this page and submit additional form(s) if needed. 6960 Market Street • Suite 109 • Boardman, OH 44512 Phone: 330-965-7600 • Toll Free: 1-800-242-5542 • Fax: 330-965-7601 E-mail: dicksoninsurance@mail.com ©2004 Dickson Insurance, Inc. All rights reserved.
NOTE: All fields marked with * are required.
# of Children
Please note: If your company has more than 25 employees, please submit this form now, then return to this page and submit additional form(s) if needed.
6960 Market Street • Suite 109 • Boardman, OH 44512 Phone: 330-965-7600 • Toll Free: 1-800-242-5542 • Fax: 330-965-7601 E-mail: dicksoninsurance@mail.com ©2004 Dickson Insurance, Inc. All rights reserved.
6960 Market Street • Suite 109 • Boardman, OH 44512 Phone: 330-965-7600 • Toll Free: 1-800-242-5542 • Fax: 330-965-7601 E-mail: dicksoninsurance@mail.com
©2004 Dickson Insurance, Inc. All rights reserved.
