Group Health Insurance North Carolina

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:
   
Total Number of Employees
(Total number employed by company)
Number of Eligible Employees
(employed 30 hrs per week or more)
Employer Contribution for Employee:
Employer Contribution for Dependents:
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