FLORIDA SMALL GROUP EMPLOYER
PLEASE FILL IN THE FOLLOWING FORM TO RECEIVE QUOTES FOR YOUR
GROUP WITH RATES FROM MULTIPLE INSURERS.  
IF YOU REQUIRE ASSISTANCE, CALL US AT
1-800- 239-7553  OR FAX TO 1-941-698-1598  
CENSUS FORM
CLICK AT PAGE BOTTOM TO SUBMIT FOR QUOTES
TAB THRU FIELDS, DO NOT HIT
ENTER
COMPANY NAME:
EMAIL ADDRESS
CONTACT NAME
STREET ADDR 1:
 CITY:
STREET ADDR 2:
STATE:
 ZIPCODE
 AREACODE
& PHONE:
FAX::
 ORIGINAL DATE OF
BUSINESS
COUNTY:
TOTAL NUMBER
FULL TIME
EMPLOYEES
(25 HRS OR MORE)
NUMBER PART
TIME EMPLOYEES
(LESS THAN 25 HRS)
TOTAL NUMBER OF
EMPLOYEES INCLUDE
ALL FT & PT
DOES COMPANY
HAVE GROUP
INSURANCE NOW?
IF YES,GROUP
INSURER NOW OR
LAST
ARE ALL EMPLOYEES
COVERED FOR WORKERS
COMP?
PERCENTAGE CO.
CONTRIBUTES TO DEPENDENT
COVERAGE?
PERCENTAGE COMPANY
CONTRIBUTES TO EMPLOYEE
ONLY PLAN?
MINIMUM 50% REQUIRED
FOR EMPLOYEE ONLY
NONE REQUIRED
PLEASE ENTER EACH EMPLOYEE'S INFORMATION BELOW.  
DO NOT INCLUDE EMPLOYEES WORKING UNDER 25 HOURS PER WEEK AS THEY ARE NOT ELIGIBLE
KEY:  EE=EMPLOYEE ONLY;  E+S=EMPLOYEE+SPOUSE;   E+C=EMPLOYEE+CHILD(REN);   FAM=EMP+SPOUSE+CHILD(REN)
MUST HAVE REASON IF AN EMPLOYEE WAIVES COVERAGE I.E.,  COV UNDER SPOUSE, OR COV ON INDV OR OTHER GROUP
PLAN IS ACCEPTABLE & WILL NOT HURT YOUR PARTICIPATION REQUIREMENT.  WE WILL HELP YOU WITH THESE.
TAB THRU FIELDS, DO NOT HIT ENTER
EMPLOYEES WORKING UNDER 25 HOURS PER WEEK ARE NOT ELIGIBLE - DO NOT ENTER
TYPE
INSURANCE
EE, E+S. E+C,
FAM
 REASON FOR
WAIVING ?
WILL EMPLOYEE
WAIVE COVERAGE
EMPLOYEE
RESIDENCE ZIP
1ST NAME,
LAST INITIAL
 MALE
FEMALE
DATE OF
BIRTH
PLEASE CLICK THE SUBMIT
BUTTON TO SEND YOUR COMPANY
INFORMATION OR CALL US AT
1-800-239-7553  OFFICE
1-941-698-1598 FAX
THE MALONE INSURANCE AGENCY
THIS FORM IS FOR GROUPS OF 2 TO 50 EMPLOYEES FOR
HEALTH INSURANCE, DENTAL, LIFE AND/OR DISABILITY
WILL THE QUOTE BE FOR HEALTH,
DENTAL, LIFE OR OTHER?
THE MALONE INSURANCE AGENCY
THE MALONE AGENCY
1-800-239-7553