— Employee Information Census—
Thank you for your interest in group health insurance quotes from Broadbent Financial Services. In order to give you the most accurate quotes possible, we request that you fill in all avaiable information. We hold to a strict privacy policy and your information will not be given to another party for any reason. All fields marked with a * are required.
General Information
* Company Name:
* Contact Person:
* E-mail:
* Phone:
Fax:
* Address:
* City:
* State:
* Zip:
Industry:
Desired Benefits & Current Insurance Information
Office Co-pay: Y N RX Co-Pay: Y N
Maternity: Y N Dental: Y N
Life: Y N Disability: Y N
Desired Deducatables:
 Hold down the Ctrl key to
select multilple deductables		 Current Health Ins Co:
Renewal Date: Full Time Employees:
Employee Information
Please fill in all fields that apply. Annual Salary is only needed if Disability Insurance is desired.
Employee Name
Gender
Age
Age of
Spouse
Coverage Desired
# of
Children
Annual
Salary
1
$
2
$
3
$
4
$
5
$
6
$
7
$
8
$
9
$
10
$
11
$
12
$
13
$
14
$
15
$
16
$
17
$
18
$
19
$
20
$

Questions or Comments:
We suggest that you print a copy of this page for your records before sending.

"The Voice of Choice" © 2007 Broadbent Financial Services
(800) 393-5371 • (435) 752-7200 • Fax: (735) 752-7521
40 W. Cache Valley Blvd. (1250 North), Ste. 3-A • Logan, UT 84341