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Group Health Census Form - Page 1
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*Contact Person:
*Email Address:
*Company Name:
*Company Address:
   *County:    *Zip:    
*Company Phone Number:
Alt. Phone Number :
*Type of Business:
*Coverage Types Desired:
(check all that apply)
*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.)
Average total number of employees/month last year
Additional Comments:

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



Aetna Insurance Blue Cross Blue Shield Insurance Cigna Insurance Humana Insurance VBA UnitedhealthOne Insurance Unitedhealthcare Insurance International Travel Health Insurance Prudential Genworth Baylor Scott & White Aliera Oscar IHC Petersen Christus Community Health Care Molina Ambetter
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