Ramsgate Consulting

Medical, Dental, Vision Insurance

Census Sheet for Groups

To request a quotation for group medical, dental or vision insurance, please complete the census sheet below. All information will be kept in the strictest of confidence and used solely for the purpose of providing the group with the plan benefit and rate information necessary to make an informed decision.

Company Name
Contact Person
Street Address
City, State, Zip Code

Phone		Fax
e-mail

Present Medical Coverage	Yes No	Carrier
Present Dental Coverage	Yes No	Carrier
Present Vision Coverage	Yes No	Carrier
Present Workers Comp Coverage	Yes No	Carrier
Workers Comp Policy Date

Total Number of Employees
Medical Benefit Components
Dental Benefit Components
Vision Benefit Components
Furnish quote by

Employee Census Details

If you would prefer to complete a printed version:

Click Here if you have 01-25 employees
Click Here if you have 26-50 employees

Groups larger than 50 employees, do not need to complete the Employee Census Details.

(Please complete dependant information for those employees with dependants unless the employee is declining coverage for the dependants.)

Name (Last, First)

Date of Birth

Residence
Zip Code

Spouse yes/no

#of children

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50