www.insureyourhealthnow.com

2863 West 95th Street, Suite 143-259, Naperville, IL 60564

866-340-5697 

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

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)