Census Form For Quoting Purposes

Instructions for completing columns 4-7

  • # of Total Members: Enter total number of members that will have regular BCBSM/BCN coverage.
  • # of Medicare Eligible: Enter total number of members that are medicare eligible but have BSBSM or BCN as their primary coverage.
  • # of Medicare Primary: Enter total number of members that are Medicare eligible and have Medicare as their primary coverage.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • List All Employees Currently On Your Payroll

  • Employee #1

  • Employee #2

  • Employee #3

  • Employee #4

  • Employee #5

  • Employee #6

  • Employee #7

  • Employee #8

  • Employee #9

  • Employee #10

  • Employee #11

  • Employee #12

  • Employee #13

  • Employee #14

  • Employee #15

  • Eligible Employee Definition: Full-time employees with a normal workweek of 30 hours or more. As a part of the total number of eligible employees, you may choose to include those working 17.5 to 30 hours as long as the eligibility criterion is applied uniformly without regard to health status-related factors.

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

This is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form. Note that any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form and/or in communications with us. All coverage is subject to the terms, conditions and exclusions of the actual policy issued.