Small Group Census

   Please Fax or Email To: gary@tis-ga.com  or  770-532-2174

   Company Name:
   Company Phone Number:
   Form Completed By:  Title:
   Company Address:
   City / State:   County:
   Business Type:
   Member / Chamber of Commerce in Dawson, Franklin, Habersham, Hall, Hart,
   Rabus, Stephens or Union Counties?
   Please list Chambers:
   Current Health Insurance Carrier:
   Employer Contribution:  %
   Current Insurance Agent:

   * Employee Name:                              Sex:                                  Date of Birth:         
  
   Family Status: 1= single  2= emp. + spouse  3= emp. + children  4= family
   Number of Children to be covered:   
  Spouse's Date of Birth:

    * Employee Name:                              Sex:                                  Date of Birth:         
  
   Family Status: 1= single  2= emp. + spouse  3= emp. + children  4= family
   Number of Children to be covered:   
  Spouse's Date of Birth:

    * Employee Name:                              Sex:                                  Date of Birth:         
  
   Family Status: 1= single  2= emp. + spouse  3= emp. + children  4= family
   Number of Children to be covered:   
  Spouse's Date of Birth:

    * Employee Name:                              Sex:                                  Date of Birth:         
  
   Family Status: 1= single  2= emp. + spouse  3= emp. + children  4= family
   Number of Children to be covered:   
  Spouse's Date of Birth:

    * Employee Name:                              Sex:                                  Date of Birth:         
  
   Family Status: 1= single  2= emp. + spouse  3= emp. + children  4= family
   Number of Children to be covered:   
  Spouse's Date of Birth:

    * Employee Name:                              Sex:                                  Date of Birth:         
  
   Family Status: 1= single  2= emp. + spouse  3= emp. + children  4= family
   Number of Children to be covered:   
  Spouse's Date of Birth:

   Medical Questions
  
   Any employee or dependents pregant? Y/N
   Has anyone been confined in a hospital in tha past 24 months? Y/N
   Are any employees currently disabled? Y/N
   Has anyone incurred 2,500 or more in medical expenses in the past 12 months? Y/N

   Has anyone received treatment for cancer; stroke; heart disorder;
   kidney disorder? Y/N

   Any other medical conditions of employees or dependants and current 
           prescription please list below.  

     Immune system disorder; psychological; alcohol or drug disorder?
   If "yes," please provide the following informaiton. If additional room is needed,
   please note this in comment box.
   Employees / Dependent Name:
   Diagnosis & Date of Diagnosis:
    
   Date(s) of treatments & Medications:
    
   Condition Ongoing?:
    
   
   Employees / Dependent Name:
   Diagnosis & Date of Diagnosis:
    
   Date(s) of treatments & Medications:
    
   Condition Ongoing?:
    

  Employees / Dependent Name:
   Diagnosis & Date of Diagnosis:
    
   Date(s) of treatments & Medications:
    
   Condition Ongoing?:
    

   Comments: