Please Check the Group Products your company wants
to make available to your employees:
Group Health   Group Dental  
Group Vision   Group Life

Underwriting Information:

List employees' names, and other census data. Dependent status is as follows: S=Single, P/C=Parent With Child, H/W=Husband and Wife, F=Family. (If More Than 10 Employees, place call us to receive a large group census form.) Emp. #1 Name:B-Date: M/F: Dep. Status S P/C H/W F Emp. #2 Name:B-Date: M/F: Dep. Status S P/C H/W F Emp. #3 Name:B-Date: M/F: Dep. Status S P/C H/W F Emp. #4 Name:B-Date: M/F: Dep. Status S P/C H/W F Emp. #5 Name:B-Date: M/F: Dep. Status S P/C H/W F Emp. #6 Name:B-Date: M/F: Dep. Status S P/C H/W F Emp. #7 Name:B-Date: M/F: Dep. Status S P/C H/W F Emp. #8 Name:B-Date: M/F: Dep. Status S P/C H/W F Emp. #9 Name:B-Date: M/F: Dep. Status S P/C H/W F Emp.#10 Name:B-Date: M/F: Dep. Status S P/C H/W F

COVERAGE INFORMATION
What Deductible or Coverage Do You Want? ($250 ded., 80% Coverage, etc.):
Any special coverages needed? (Contact Lens Cov. Lasik Cov., etc.)
Tell Us What You Want MOST in your Vision Plan, or list any other Remarks here:

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