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USFSB Health Insurance Recommendations	Insurance Glossary
Return to the Insurance Clearinghouse

Census Form Part 1

Thank you for your interest in Health Savings Accounts. By completing and submitting our company census form, you will receive recommendations and quotes for the HSAs that most closely match your needs.

The first step is to complete your company information and click on the "Submit Census" button at the bottom. You will then need to add information about your employees.

Company:

Address:

City:

State: Zip:

Name-Salutation: First: Last:

Phone:

Fax:

Email:

How did you hear about USFSB?

Please describe the nature of your business (examples: Restaurant, Insurance Agency):

Bus.Type:

Do you currently have health insurance coverage?

Yes

Do you currently have an HSA?

Yes

If you answered yes to either of the above questions, who are you currently covered through?

Indicate your preferred deductible amount. The higher the deductible, the lower the monthly insurance premium will be.

Please indicate other riders that you may need your insurance plan to retain. (For example - Mental Health, Chiropractic, Physical Therapy, student rider, etc.)

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USFSB Health Insurance Recommendations

Census Form Part 1