Small Census

Small Business Quote < 10 Employees

Complete this form online for the quickest turn-around time or If you prefer,you can print and fax the form to us at 269-381-8944.

Instructions:
1. Check what types of quotes you would like for your group.
2. Provide your business information.
3. Enter your industry type. (Ex: Excavation, Machine tool, restaurant , etc.)
4. Provide the name of your current carrier. Enter NONE if you currently do not have group coverage.
5. Fill in your groups full-time employee demographic information.
   (It is not necessary to use employee name. Instead use Employee 1, Employee 2, etc..
    or some other form of unique designation)
    For each employee, enter the employees unique designation, male/female, age and coverage
    code.
    If including a spouse or child (children) please include male/female and age of each.
    Continue with each employee until all employees have been entered for your group.
6. Provide information about any known medical conditions that exists in the group. To protect
    your employee's privacy, DO NOT include any information about who the condition applies to.
7. Enter any additional information about your group that might be helpful for quoting purposes.
8. Click your preferred method of contact.
9. Click "Submit"

Coverage Codes:
Employee Only =	E
Employee + 1 (Employee + Spouse or Employee with 1 child) =	E + 1
Employee + Children ( Single Parent with 1 or more children) =	E + C
Employee + Family =	F

* indicates required fields

*Type of Quotes Requested:

Group Medical
Group Life
Group Dental
Group Vision
Group Disability (Short-term / Long-Term)
Health Savings Account
Health Reimbursement Account

*Business Name, Address, City, State and Zip Code:

*Phone #, Fax # or E-mail Address:

*Your Industry Type:

Current Carrier:

1 Employee, Male/Female, Age and Coverage:

2 Employee, Male/Female, Age and Coverage:

3 Employee, Male/Female Age and Coverage:

4 Employee, Male/Female, Age and Coverage:

5 Employee, Male/Female, Age and Coverage:

6 Employee, Male/Female, Age and Coverage:

7 Employee, Male/Female, Age and Coverage:

8 Employee, Male/Female, Age and Coverage:

9 Employee, Male/Female, Age and Coverage:

List any Known Medical Conditions in Group:

Additional Information:

Preferred Method of Contact:

Phone
E-mail
Fax

When completed "click" the SUBMIT button.

Once received, Miller-Schuring agency will prepare an exclusive group insurance quote spreadsheet for your group using the above information. It may be nessacary to contact you for additional information.

PO Box 2133 Kalamazoo, MI 49003
5136 Lovers Lane Suite 104, Portage, MI 49002
Phone: 269-381-9442 Toll-Free 1-800-315-8740 Fax: 269-381-8944

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