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Summary of Benefits Form
Name of Company:
Address:
City, State, Zip:
SIC:
Effective Date:
Deductible:
Coinsurance:
Out of Pocket:
Office Visit Copay:
ER Copay:
Rx Copay:
Lifetime Maximum:
Annual Premium:
Wellness:
Preventive Care:
 

Census Form
Name of Company:
Address:
City, State, Zip:
SIC:
Effective Date:
(EE=Employee Only) (EE/SP=Employee + Spouse) (EE/CH=Employee + Child)
(F=Family) (FT=Full Time) (PT=Part Time)
Gender DOB Employee Home Zip Code Medical Coverage FT/PT Cobra
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9
 
3815 River Crossing Parkway • Suite 100 • Indianapolis, In 46240
Phone: (866)259-5020 • Fax: (317)705-0050 • Email: jack@greatmidwesternfinancialgroup.com

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