Ramsgate Consulting

Medical, Dental, Vision Insurance

Census Sheet for Individuals and Families

To request a quotation for individual or family 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 you with rate information necessary to make an informed decision.

Rate information is available only for residents of the state of California.

Applicant Name
Street Address
City, State, Zip Code

Phone		Fax
e-mail

Name (Last, First, MI)

Soc. Sec. No.

Date of Birth

Height*

Weight

Applicant
Spouse
Child 1
Child 2
Child 3
Child 4
Child 5

* Please show height in inches not feet and inches.