Group Health Census — Conde Agency

Business Information

Business Legal Name *

DBA / Business Name

Complete this field if the company operates under a name different from its legal entity name.

Contact First Name *

Contact Last Name *

Contact Email *

Contact Phone Number *

Street Address *

City *

State *

ZIP Code *

Business County *

County where the business is located. We suggest one based on your ZIP code — please correct it if needed.

What type of business is this? *

Briefly describe what the business does *

Total Number of Employees *

Employees to include in this quote *

Does the business currently offer health insurance? *

Desired Coverage Effective Date

When would you ideally like the new coverage to begin?

Do all employees primarily work in the same county? *