Group Health Census for Quotes - Member Insurance Solutions

Group Information

Full Legal Group Name(Required)

BCBSM Group No. / Suffix(s) (if applicable)

BCN Group ID/Subgroup ID/Class ID (if currently enrolled)

Group Address (Physical Location)(Required)

Street Address City State ZIP Code

Proposed Effective Date(Required)

Rate Renewal Date (if currently enrolled)

SIC Code and/or Type of Business

List All Employees Currently On Your Payroll

Add Employees

Employee Name	Actions

There are no Employees.

Number of eligible employees in Michigan:

Number of eligible employees outside of Michigan

Total

Your Information

Name of person completing this form(Required)

First Last

Date

Phone(Required)

Name of rep/agent

This is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form. Note that any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form and/or in communications with us. All coverage is subject to the terms, conditions and exclusions of the actual policy issued.