Firm Name:
Contact Name:
FALSS Member Name:
Address:
City:
State:
Zip:
Phone Number:
E-mail Address:
Fax Number:
Business Entity:
# of full-time employees in firm:
# of employees enrolling:

Types of coverage desired:






Long Term Care

 
Name of current health insurance provider/company:
Comments:
How did you find us?

Employee only = ee
employee+spouse = es
employee+child = ec
family = esc

Confidential Firm Census

Please include all full-time employees, even if not covering (if requesting quotes for LTD, Life, and Work Comp, income information is required)

Name (optional, you may also indicate EE1, EE2)
Sex
Date of Birth
Position
Income (optional)
Coverage
Desired
Ex
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20