Health – Group CensusEmet Digital2019-01-02T12:32:59-08:00 Get started by filling out this form and someone from our team will contact you shortly! Health - Group Census COMPANY INFORMATIONCompany Name* Business Operations* Please provide a precise description of what your company does.Address* Street Address City State / Province / Region ZIP / Postal Code Phone*FaxEmail* Enter Email Confirm Email Do you currently have a health plan? Yes No What is your current health plan?* What type is your current health plan?* HMO HSA PPO POS EPO Dual Option Please check all that apply.What is the premium for your current health plan?* Do you have more than one location?* Yes No Address* Street Address City State / Province / Region ZIP / Postal Code Any employees paid by commission (and/or) paid as independent contractors? (FORM 1099)* Yes No Any COBRA participants previously employed by you?* Yes No What types of employees would you like to be quoted?* All Salary Management Non-Union Hourly Number of full-time employees*Full-Time is 30 hours per week or more.EMPLOYER PAYMENT OPTIONSPercentage of costs to be paid for employees*Percentage of costs to be paid for dependents*What date do you want this to be effective?* MM slash DD slash YYYY PROPOSAL OPTIONSWhich products are you looking for?* All Medical Dental Life Vision Please check all that apply.Which plan designs are you interested in?* All HMO HSA PPO POS OTHER Please check all that apply. COMPANY CENSUSPlease provide the following information for each of your employees. If you have more than 10, please upload the information in a spreadsheet format using the option below.Employee #1Name* Date of Birth MM slash DD slash YYYY Plan Type Medical HMO or PPO Dental HMO or PPO SexMaleFemaleSpouse?YesNoNumber of childrenCobraYesNoHome Zip CodeLife Only*YesNoLife AmountNameThis field is for validation purposes and should be left unchanged.