CENSUS FORM

To receive a FREE, no obligation quote for Group Medical and/or Group Dental Insurance, please fill out and submit the following form. If you have any questions, you can call us at 1-800-875-4490.

You may also print this form and fax it to us at: 1-253-896-9411.
Company Name:
Contact's Name:
E-Mail Address:
Type of Business:
Owner's Name:
Street Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Fax:

What type of insurance are you looking for?

Medical       Dental
Other: 
Current Medical Carrier:
Plan Type:
Current Dental Carrier:
Plan Type :
Renewal Date:
Employeer Pays: % of Employee Premium
Employeer Pays: % of Dependents Premium

How did you hear about Maddock & Associates?



Questions or Comments


Please complete for each employee

  Name Sex Age/DOB Type of Coverage Spouse Age/DOB # of
Children
1 Employee Name
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 #Children
2 Employee Name
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 #Children
3 Employee Name
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4 Employee Name
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5 Employee Name
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6 Employee Name
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7 Employee Name
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8 Employee Name
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9 Employee Name
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10 Employee Name
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11 Employee Name
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12 Employee Name
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13 Employee Name
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14 Employee Name
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15 Employee Name
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Female 		Age/DOB
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16 Employee Name
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Female 		Age/DOB
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17 Employee Name
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18 Employee Name
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Female 		Age/DOB
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19 Employee Name
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Female 		Age/DOB
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 Spouse Age
 #Children
20 Employee Name
 Male
Female 		Age/DOB
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 Spouse Age
 #Children


            
E-mail us for more information and a free quote or CALL TOLL FREE
1-800-875-4490 (in the U.S.) or 1-253-854-0199 (outside the U.S.)
Fax: 1-253-896-9411

Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424
Serving all of Washington at 800-875-4490, Seattle at 206-682-1628,
Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291.
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