New Hampshire Group Census Information:

Please fill out this employee census or print out and fax a copy of your company's census to 603-218-6447. Be sure you have also completed an online group quote request or call us directly at 1-877-842-1846.

* = Required Information

Contact Information:

First Name*
Last Name*
Company*
Phone Number*
Email*

Employee Census Information:

 
Please include census data on all eligible, participating, employees.
Employee Name
Zip
Gender
DOB
Age
Coverage Type
# of children
Dental
Other Benefits