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: