Coverage is available without regard to medical history for all full time employees.
This makes group life a very valuable benefit for employees who have health problems that make them difficult to insure.

Name of Employer:

E-MAIL Address:

What does your business do?

Amount of Coverage Desired on each employee?
$10,000
$25,000
$50,000

Do you want a quote on group disability as well? Yes No

If "No," leave the salary blank.

Census
Name:   Age:   Salary:
Name:   Age:   Salary:
Name:   Age:   Salary:
Name:   Age:   Salary:
Name:   Age:   Salary:
Name:   Age:   Salary:
Name:   Age:   Salary:
Name:   Age:   Salary:
Name:   Age:   Salary:

For groups larger than nine employees, please fax us this information at
(703) 368-2742, or e-mail it to us at brownsins@aol.com. Larger amounts of
coverage are available for larger groups.