Apex Benefits Insurance Agency

On-Line Company Census
All information will be kept confidential

Contact Information:

Name:		Company:
Address:		Telephone:
City:		E-mail:
State:	Zip Code:
SIC Code or Business Description:

What type of benefits are you interested in offering your employees? (check all that apply)
	Medical Insurance Dental Insurance Vision Care Insurance	Short-Term Disability Insurance Long-Term Disability Insurance Life and Accidental Death & Dismemberment Insurance
Envisioned start date with new benefit plans?

Employee Information:	Coverage Level:	Age:	Gender:	State:	Zip Code:
1) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female
2) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female
3) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female
4) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female
5) Name: Annual Salary: Job Title:	Ee Only Ee + Spouse Ee + Child Family		Male Female
6) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female
7) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female
8) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female
9) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female
10) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female
11) Name: Annual Salary: Job Title:	EE Only EE + Spouse EE + Child Family		Male Female

Please Note: Click the Submit button only once. This form does not clear itself of information upon submittal.

Apex Benefits Insurance Agency - License Number 0D60950