Group Health Insurance Date Date Format: MM slash DD slash YYYY Contact Name First Last Contact Phone NumberGroupReferred ByCurrent CarrierNature of Business or SIC CodeInclude Disability?YesNoInclude Dental?YesNoInclude Vision?YesNoInclude Life Quote?YesNoLife Insurance AmountContact Phone NumbersActive EmployeesPlease list all active employees, if they will be including spouse or dependent children please entre under "name" spouse, son or daughter and give the date of birth. An employee may use your business zip code for residence zip code. Note: If an employee is not participating please give an explanation: Part Time (PT), Insured With Spouse (IWS), Own Individual Policy (OWN), Other Health Program (OHP), Ineligible or Declined. Health Insurance Category: EE Only - Employee Enrollment Only EE+Spouse - Employee and Child or Children EE+Dependent -- Employee and Child or Children Family - Employee, Spouse and Child or Children If life benefit is included, please list those who qualify for life benefit but are not enrolling in the health plan. Life Insurance Category for those not enrolling in Health Benefit: Life EE Only; Life EE+Spouse, Life EE+Dependents; Life FamilyList of Active EmployeesOn each line, include: Name, Sex, DOB, Category, # Dependent Children, Hire Date, Resident Zip CodeKnown Medical ConditionsWithout disclosing names, please list any known medical conditions in groub and how long condition has existed.