Download Blank Group Census Page

Thank you in advance for downloading our group request form.  If you have you own form you may submit it to us.
You can fax it to 888-464-0061 or email it to tgallanis(at) 

  1. We only need minimal information to prepare a proposal for you.
  2. Employee age or DOB, Initial or first name 
  3. Home Zip code of employee
  4. If you are adding spouse or children please include in census.

If you have any questions we are available to answer them for you.  
Thank you for requesting a group proposal, if you like our proposal, service and timely response, we want to be your group health insurance broker and agent. 

Best regards,

Tom Gallanis
CA Insurance lic 0703175
Licensed since 1988

Click this download link: Group Census Form (13 downloads)
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