Full Name:

Day Telephone:

Street Address:

Eve Telephone:

City, State & Zip:

Fax:

E-Mail Address:

Best Time To Reach You: Select Mornings Afternoons Evenings Weekends Anytime

Dental Ins. Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/A)

Vision Plan Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/A)

List employees' required census data:

Employee # 1 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:
Employee # 2 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:
Employee # 3 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:
Employee # 4 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:
Employee # 5 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:
Employee # 6 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:
Employee # 7 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:
Employee # 8 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:
Employee # 9 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:
Employee #10 Status:	Select One Single Husband/Wife One Parent/Child Family	Age: M/F:

Any Covered Persons Have Specific Dental or Vision Insurance Needs?
(If yes, descibe in detail, and to which of the insured persons they apply.)