Step 1 Applicant Information Business Name Contact Name Phone Number Fax Email City State AK AL AR AZ CA CO CT DC DE FL GA IA IL IN KS KY LA MD MI MN MO MS MT NC NE NM NV OH OK OR PA SC SD TN UT VA WI WV WY Zip Code Nature of Business Current Carrier Current Monthly Rate Total # of Employees Step 2 Personnel Census Name and/or CodeCoverage TypeSexEmployee DOBSpouse DOBNo. Children Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Employee OnlyEmployee&Spouse Employee&ChildrenFamily MaleFemale Step 3 Plan Information Plan Type Any HMO Major Medical PPO Deductible Any 0-1000 1000-2500 2500-10000 Doctor Copay Yes No Coinsurance Any 100/0 50/50 70/30 75/25 80/20 None Rx Card Yes No Maternity Care Yes No Dental Yes No Effective Date 01/01 01/15 02/01 02/15 03/01 03/15 04/01 04/15 05/01 05/15 06/01 06/15 07/01 07/15 08/01 08/15 09/01 09/15 10/01 10/15 11/01 11/15 12/01 12/15
