Click here for Individual Quotes
Click here for Medicare Supplement
Click here for Group Employee Census

  
Please complete and submit the information below and we'll send you the appropriate insurance census forms by email, fax or priority mail, which you can complete and return by fax, email or regular mail.
  

Contact Name and Address

First Name
Last Name

Address
City
State
Zip Code

Coverage Types

Group Health
Group Life
Group Dental
Group Short Term Disability
Group Long Term Disability

Current Plan

None
Don't Know
HMO
PPO
Major Medical
 

Requested Plan

Don't Know / Best Proposal
HMO
PPO
Major Medical
 
 

Additional information, questions or comments.

How would you like to receive your Census forms?
by Courier  by eMail  by Fax  by Priority Mail 

Please call us, if you have a question or need assistance in completing this form
or your census forms when you receive them.
 

Thank you,
Customer Support

Our Privacy Guarantee:
We will use the information you have provided to help you find Health Insurance. Your information will be held in the strictest confidence by Insurance Matters, Inc. We will not sell, rent or lease your name, email address, or phone number for any other purpose. However, our privacy guarantee does not apply to your relationships with other financial institutions, including, but not limited to banks, finance companies, mortgage companies and the insurance companies that information is supplied to by you. Please check with each provider's privacy policies as to how they collect, use, and disclose personal information that you allow them to access.