Jordan Benefit Services

Sales Rep:

Agent Name: Sara Jordan

PO Box 3

Castroville, TX 78009

Phone: 210-421-8361

Fax:

sarajordan@peoplepc.com

http://www.jordanbenefits.com

Group Name:

Address:

City, State and Zip Code:

Nature of Business / SIC:

Requested Effective Date:

Current Carrier:

Current Coverage:

HMO / PPO:

Office Visit

Coinsurance:

Deductible:

Out of Pocket:

Rx:

Medical: HMO / PPO / POS / HSA

Please Circle Requested Coverages:

Ancillary: Dental / Vision / Life / LTD / STD

Requested Carriers:

Total # Full-Time Employees:

EE CENSUS

Sex

DOB / Age

Coverage TypeEO, ES, EC, EF

Home Zip Code

Salary

Enrolled in Medicare

COBRAEnd-date

EE 1

EE 2

EE 3

EE 4

EE 5

EE 6

EE 7

EE 8

EE 9

EE 10

EE 11

EE 12

*** Note *** Coverage Types (EO = Employee Only / EC = Employee Child(ren) / ES = Employee Spouse / EF = Employee Family)

Please Attach Additional Sheets if Needed