Group Census

Small Group Coverage from JAR Insurance Services

Small Group Coverage

from JAR Insurance Services

Group Information

NOTE: Before you begin, please download our small group census template here. You will be required to upload it later in the form.

    Medical Information

    Does Employer currently have Group Coverage for? (Please check all that apply)
    MedicalDentalVisionLife

    If yes, please attach a copy of your most recent statement

    THEN complete the following:

    Current Benefits

    For medical coverage, carrier requires a minimum contribution of 50%*

    Medical

    (Please check all that apply)
    HMOPPOHSAPOSHMO/POSHMO/PPOLifeDentalVision

    Do you have workers’ compensation insurance?

    YesNo

    If yes, please upload the completed census form given at the top of this page or download it here

    Additional Comments:

    Your Email: