Group Enrollment Form Please fill out the form below and one of our representatives will reach out to you shortly! "*" indicates required fields Name of Group*How many total employees?*Eligible Employees?*Employees Enrolling?*State group is located in?* State / Province / Region Requested Effective Date* MM slash DD slash YYYY Multi-Location Group? (must be in different counties)* Yes No Common Ownership?* Yes No Agent quoting contact information:Name First Last Company*PhoneEmail Are you the current/in force agent?* Yes No If No, explain (explanation not required)Are you currently appointed with all carriers quoting?* Yes No Please be sure to obtain the following: Census from the group in excel format ONLY, including Name, gender, DOB, resident zip code, and coverage elections (including waivers) *Please note UHC requires dependent information if group size is 51-99 Current and Renewal Rates for each line quoting Current Benefit summary for each line quoting CommentsEmailThis field is for validation purposes and should be left unchanged. Δ