www.insureyourhealthnow.com

3108 South Route 59, Suite 124 - 259, Naperville, IL 60564

866-284-7372 - fax 866-375-7164

info@insureyourhealthnow.com

I would like more information on the following:

[ ] Group Health       [ ] Individual Health       [ ] Supplemental        [ ] Dental       [ ] Life
Business Name:________________________          Contact:_____________________________
Phone #:_______________________________ Fax#:_______________________________
Address:_______________________________ City:________________________________
Type of Business_________________________ State:______________Zip Code:_________

PLEASE COMPLETE CENSUS

(For fast response, fax to 866-375-7164)

Employee Age or Date of Birth

Gender

Spouse Age or Date of Birth

Number of      Children    

Type of Coverage*  

1

 F      M

      
2

 F      M

      
3  F      M      
4  F      M      
5  F      M      
6  F      M      
7  F      M      
8  F      M      
9  F      M      
10  F      M      
11  F      M      
12  F      M      
13  F      M      
14  F      M      
15  F      M      
16  F      M      
17  F      M      
18  F      M      
19  F      M      
20  F      M      

        *Types of Coverage    

E          Employee only
E+S     Employee & Spouse
E+C     Employee & Children
F          Family ( Employee, Spouse & Children)