Preferred Insurance of Colorado Springs

Serving Colorado's Health Insurance Needs Since 1989

  5527 N. Union #100
Colorado Springs, CO. 80918
Office: (719) 599-7989
Fax: (719) 599-7897

Group Data and Census Sheet

If you would like a quote on your small business, please complete this Group Data and Census Sheet.

Group Name

Address

City
 State
 Zip
Contact Person
 Phone

Effective Date

Nature of Business
 How Long?
Current Carrier
 How Long?

Description of Current Plan

Dental
 Prescription
Employer Contribution of
%		 SGL
 FAM

Below, please check any employees / depentents to which the following may apply.

Pregnant / Delivery Date
Retired
Disabled / Type of Disability
Cobra / How Long

Explain

Census

Date of Census

Employee Name Date of Birth Sex Status


Copyright © 2006 All Rights Reserved. • Preferred Insurance • Colorado Springs, Colorado