Small Group Health Small Group Health Quote Small Group 2-50 Step 1 of 2 50% SMALL GROUP CENSUS 2-50 EMPLOYEESNote: Click the "+" to the right to add more rowsCompany Name* Contacts Name First Last PhoneEmail Enter Email Confirm Email Primary Mail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employee Enrollment InformationReference: EE = Employee Only, ES = Employee + Spouse, EC = Employee + Child, EF = Employee + Family, SP = Spouse, CH = Child (examples Employee + SP = ES/SP Employee ListFirst NameLast NameDate of BirthAgeZip Code The zip code is the zip code where the employee / dependents reside INSURANCE HISTORYDo you currently have a small group health plan in force or have you within the last 60 days? Yes No Name of the Health Plan Is the plan currently active? Yes No
