Group Health Insurance North Carolina

This Group Health Insurance Census Form may be used for groups of 25 or less employees. For groups larger than 25 employees, complete the 26+ Census Form and fax to 919-287-2777.

To provide the fastest possible service we will send your Quote via Email. In order to deliver the most competitive pricing we may need to contact you via telephone. Only one of our representatives will call to verify your quote or get any additional information needed.

Company Name:
Address: (Line 1)
(Line 2)
County:
City:
State:
Zip Code:

Nature of Business:
Contact Name:
Email:
Telephone: (with Area Code)
Current Carrier:

Build Your Own Plan

Total Number of Employees
(Total number employed by company)

Number of Eligible Employees
(employed 30 hrs per week or more)

Requested Effective Date of Coverage:
Select the Deductible Amount:
Select the Coinsurance Percentage:
Coinsurance Maximum Out of Pocket:
Doctors Office Visits Co-Payments:
Prescription Drug Co-Payments:
Health Savings Account (HSA) Plans:
Select HSA CoInsurance:
Employer Contribution for Employee:
Employer Contribution for Dependents:
Comments

Jerry Ballard & Associates, Inc. Local: 252-726-5400 Toll Free: 888-765-5400 A name you can trust, an agent you can count on. Serving North Carolina residents since 1974.