Group
Health Plans of La.
4323 Division St. # 104, Metairie, La. 70002
Phone
504-456-1858/Fax 504- 885-4640
Out of area 1 888 456 1858
www.ghpla.com
(PRINT THIS FORM AND FAX IT)
or go to
Census
online.htm
Name of
Company:______________________Address:________________________ Zip
Code____________
Owner's Name_________________________
*Contact name and Title:________________________________
Type of
Business_______________________ (Contact must be
owner if less than 10 full time employees)
# of full time
employees:__________________ Location of offices not in
Louisiana_______________________
Ph# (___)______________ Fax#
(____)______________ email
address:___________@__________________
Please submit a copy of the last
month's billing from your current insurance company. (Required for
quotes)
The one thing I most want to
accomplish by a change in health insurance companies/plans
is:
_________________________________________________________________________________________
_________________________________________________________________________________________
Would it be a benefit to your company
to have benefits and provider directories on the
internet?_____________
Do you want to offer voluntary benefits
like dental,vision,accident,cancer,disability, or
life? _____________
|
sex |
age/dob |
ee |
ee+sp |
ee+ch |
family |
Health Conditions? | |
|
1 |
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|__________________________ |
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2 |
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3 |
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|__________________________ |
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4 |
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5 |
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6 |
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7 |
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8 |
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9 |
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10 |
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11 |
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12 |
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13 |
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14 |
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15 |
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16 |
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17 |
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18 |
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19 |
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20 |
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21 |
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22 |
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23 |
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24 |
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25 |
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|__________________________ |
CODE: ee=employee,
ee+sp=employee+spouse, ee+ch=employee+child, family=both spouse +
child(ren)
census.doc