All information acquired by Dickson Health Insurance is kept strictly confidential and will not be shared with mailing lists or "spammers". NOTE: All fields marked with a red asterisk (*) are required.  GROUP CENSUS SHEET * Name of Company: * Nature of Business: (complete description and SIC code) * Business Address: * County: * Zip Code: * Company Phone: * Company Fax: * Contact Person: * E-Mail Address:  PRESENT INSURANCE PLAN INFORMATION * Name of Insurance Company: * Deductible: $ Monthly Premium Amount: Please check if your plan has:  Doctor Visits Copay Drug Card Dental AD&D Life (Amount) Other CENSUS CODES: EE-Employees  ES-Employee & Spouse  EC-Employee & Child  F-Family  LO-Life Only Name Sex EE Date of Birth (xx-xx-xxxx) Spouse Date of Birth (xx-xx-xxxx) PLEASE CHECK IF APPLIES M F EE ES EC F # of Children LO Please note: If your company has more than 25 employees, please submit this form now, then return to this page and submit additional form(s) if needed.