Commercial Insurance Solutions Form

GROUP SPONSOR INFORMATION

Employer Union Association Credit Union Other

GROUP NUMBERS

Total number of members

Gender Distinction (approximate)

Age Distribution (approximate)

Job Classification Distribution (approximate)
Management		Clerical
Professional		Temporary
Skilled		Other

If this is a multi-location Group, indicate approximate number of members at each location
Location	No

ADDITIONAL COMMENTS

Please take a moment to tell us how you heard about us:

Please tell us who refered you:
^*(If it was a friend please write their full name in the space below)

ADDITIONAL COMMENTS