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Group Health Census Form - Page 1
* indicates required
 
 
*Contact Person:
 
*Email Address:
 
*Company Name:
 
*Company Address:
 
*City:
State:
   *County:    *Zip:    
 
*Company Phone Number:
 
Alt. Phone Number :
 
*Type of Business:
 
 
*Coverage Types Desired:
(check all that apply)
Health
Life
Dental
Vision
Disability
Accident
 
*Coverage Start Date:
 
*Number of Employees:
(Minimum 2. Employee = 30 plus work hours average per week in the business and receives a paycheck with taxes taken out.)
 
*ATNE:
Average total number of employees/month last year
 
Additional Comments:
 


 
Caution: Please check that the above
information is correct before proceeding.

 

 

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Darrell and Maggie Been
7906 North Wellington Court, Houston, Texas 77055

Office 281-239-6966   Texting 281-239-6966   Toll Free 1-888-239-6966   Darrell’s cell 281-455-0547
darrell@beenbenefits.com   maggie@beenbenefits.com