Krist Insurance Group Group Health Insurance Quotation

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General Information

Business Name
Contact Person
First Name
Last Name

Primary Address of Business
Address 1
Address 2
City State Zip

Other Locations
E-Mail
Phone Number
Fax Number:

Please fill out Census form below:

1.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

2.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

3.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

4.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

5.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

6.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

7.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

8.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

9.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

10 .	Name: Sex: M F Age as of effective date: Spouse age: Children number:

11.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

12.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

13.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

14.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

15.	Name: Sex: M F Age as of effective date: Spouse age: Children number:

Changes to census in next year:

Additions to census in past year:

Current carrier:
Annual anniversary date:
Percentage of last increase:

Health issues within group:

General description of known claim activity:

Any other comments:

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The Krist Insurance Group, Inc. DBA Krist Insurance is a multiline Insurance Agency located in Des Moines IA. Licensed in Twelve states, The Krist Insurance Group Inc only does business where licensed. All Internet inquiries are compared to our licensed states list prior to any coverage or rate determination. If an inquiry comes from a non-licensed area, and if determined feasible, Krist Insurance Services may pursue licensing in non-licensed states prior to responding to coverage inquiries, or effecting coverage. The Krist Insurance Group, Inc. DBA Krist Insurance Services does not do business over the WEB for non- licensed states.