TEXASGROUPANDINDIVIDUALHEALTHINSURANCESPECIALISTS.COM

Dear Employer:

For a Group Proposal Quote, please complete the Employer Census and two page Employer Questionnaire listed below and e-mail to shortino@verizon.net or fax it to us at (972) 414-7065.

We will obtain the most competitive plans and premiums for your group.

Effective 2010, as an employer you may be eligible for a 25% or 35% Tax Credit by the IRS to provide a Group Medical Plan for you and your employees.

Thank you,

Joe Shortino

(972) 414-7168

1-(866) 994-9091

SHORTINO & ASSOCIATES

                                                                              P.O. BOX 451238

GARLAND, TX 75045-1238

Phone: (972) 414-7168

Toll Free 1 (866) 994-9091

Fax: (972) 414-7065

shortino@verizon.net  

Group Census

Company Name:______________________              Type of Industry:________________

Company Address:________________________________________________________

                               ________________________________________________________

Phone:____________________________  Fax:_________________________________

Effective Date:_________________

Company contact name and e-mail/fax #: ______________________________________

                                                                   ______________________________________

Employee Name	Date of Birth	Sex	Dependent Status*	Smoker/             Home Zip Code  Employment Non-Smoker                                         Date

*  E    = Employee Only

    E/S = Employee & Spouse

    E/C = Employee & Children (# of children)

    E/S/C = Employee, Spouse & Number of Children

SMALL GROUP EMPLOYER MEDICAL QUESTIONNAIRE

Comple   Complete the following questions to the best of your knowledge for eligible employees, their dependents, and any                 COBRA participants, state continuation participants, or state dependent continuation participants.
1.               1.  How many employees or dependents have had a claim of $5000 or more in the past 12 months?
2.  How many employees or dependents have been advised to have surgery or medical treatment in the past 6 months that has not                      yet been performed, or been hospitalized or had surgery in the past 3 years?
3                3.  How many employees or dependents have been advised, diagnosed, or treated by a physician in the past 5 years for:
(Enter the number of employees or dependents with the condition and provide details on the next page.)
A.             Stroke	Heart Disease or Disorder
Circulatory Disease or Disorder	Vascular Disease or Disorder
High Blood Pressure
B.  ______Cancer	Tumors
Leukemia	Lupus
Chronic Skin Condition	Any other Systemic Disease
C.               Multiple Sclerosis	Paralysis
Osteoarthritis	Other Severe Arthritis
Joint Disorders	Back Disorders
Muscle Disorders	Bone Disorders
D.               Asthma	Emphysema
Respiratory and Lung Disorders
E.               Diabetes	Pancreas
Growth Disorder	Endocrine Disorder
F.               AIDS	Tested Positive for HIV
Immune System Disorders	Blood Disorders
G.               Hepatitis	Liver Disorder
Digestive System Disease or Disorder	Colon Disorder
Kidney Disorder	Prostate Disorder
Reproductive Organs Disorder	Infertility
Urinary Tract Disorder
H.               Nervous System/Brain/Seizure Disorders	Mental/Emotional Disorders
Alcohol/Drug/Substance Abuse or Dependency
I.              Organ Transplant	Bone Marrow Transplant
J.             Other
4.   How many employees or dependents are currently pregnant?

     If you have indicated medical conditions on the previous page, please provide details for each person with the condition.

     If more than one person has the condition, add a separate entry for each person.  See the example in the first line.

Name of Person with Condition (Optional)	Age	Gender	Relation to Insured*	Condition/ Diagnosis Details	Treatment/ Medication Details	Date(s) Treated	Current Status
John Doe appendicitis	12	M	Child	Appendicitis	Surgery to remove appendix	01/01/99     to     01/05/99	Full recovery

  * Employee, Spouse, Child

   I certify the information is complete and true to the best of my knowledge.

  Authorized Company Officialýs initials here: ________ Agentýs initials here, if applicable: ________