North Carolina Group Health INsurance Census Form

Jerry Ballard
(Agent/Owner)
Toll Free: 888-765-5400
Phone No.: 252-726-5400

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North Carolina Group Health Insurance Census Form

This Group Health Insurance Census Form may be used for groups of 25 or less employees. For groups larger than 25 employees, complete the 26+ Census Form and fax to 252-727-5400.

To provide fast service, where possible we will send your Quote via Email. In order to deliver the most competitive pricing we may need to contact you via telephone. Only one of our representatives will call to verify your quote or get any additional information needed.


Company Name:
Address: (Line 1)
(Line 2)
County:
City:
State:
Zip Code:

Nature of Business:
Contact Name:
Email:
Telephone: (with Area Code)
Current Carrier:

Total Number of Employees
(Total employed by company)

Number of Eligible Employees
(employed 30 hrs per week or more)

Desired Effective Date of Coverage
Select the Deductible Amount
Select the Coinsurance Amount
Employer Contribution for Employee
Employer Contribution for Dependents
Comments:

NCHealthplans is an independent authorized producer/agency licensed to sell and promote products from Blue Cross and Blue Shield of North Carolina® (BCBSNC®). The content contained in this site is maintained by NCHealthplans. Blue Cross and Blue Shield of North Carolina® is an independent licensee of the Blue Cross and Blue Shield® Association. ® Registered mark of the Blue Cross and Blue Shield Association (SM) Service mark of the Blue Cross and Blue Shield Association®