Independent Insurance Agent
Financial Consultant
Lettie Tice
P. O. Box 61321
St Petersburg, FL 33784-1321
Phone: 717-541-2173
Email: silversgold@aol.com
Fax: 727-541-1704
 
 
_____________________________________________________________________________________________ Census
YOU HAVE REQUESTED A QUOTE PLEASE FILL IN AND RETURN THIS FORM
WE CAN MANY TIMES PROVIDE BETTER COVERAGE FOR THE MONEY.
THANK YOU FOR YOU CONSIDERATION OF OUR SERVICES
Key for type of coverage for employees:
EO = Employee Only ES = Employee and Spouse

EC = Employee and Children
EF = Employee, Spouse, and Children HMO = PPO =
Name of Business
Type of Business
Business Address City
State Zip 		County
Phone Alt Phone Best time to Contact AM PM
Contact Person Position  
Type of Plan:  Individual Group  
Number of Employees Full Time Part Time
Desired Effective Date
 Employee Contribution
Yes No 		 
Current Premium
 Last Date Paid
 HMO PPO
Other
Company Prescription Yes No
Only fulltime employees over 25 hours per week  

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other
If you have additional employees please click here    Waivered Employees with other coverage they will keep.Click here
Doctor Preferred Address City Zip
Phone
Reason for Changing
 
Additional Employees

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other
Return to form completion
List of Waivered Employees:

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other

Employee

Name
Age
Sex
Female Male
Height
Weight
Date of Birth:
Tobacco Usage
Yes No
Health Problems
Yes No
Hire Date
Zip Code

County of Residence
FT PT
Income base
1099
W2
Corporation
Other
Return to form completion
 
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