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Ron Powell & Associates LLC Group Census Form

GROUP NAME: GROUP ADDRESS: EFFECTIVE DATE: TYPES OF COVERAGE INDUSTRY SIC: EE = EMPLOYEE ONLY ES=EMPLOYEE & SPOUSE EC=EMPLOYEE & CHILDREN F= FAMILY W=WAIVE COVERAGERequesting agency: Ron Powell & Associates 1300 McGee Drive, Suite 105 Norman, OK 73072 (405) 321-0101 fax (405) 321-0105 ronpowellinsurance@outlook.com NAME/INITIALS GENDER EMPLOYEE DOB/AGE SPOUSE DOB/AGE CHILD 1 AGE/DOB CHILD 2 AGE/DOB CHILD 3 AGE/DOB CHILD 4 AGE/DOB COVERAGE 1. 2. 3. 4. 5 6. 7. 8. 9. 10. 11. 12 13 14 15 16. 17. 18. 19. 20.
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DISCLAIMER: www.ronpowellinsurance.com website is owned and operated by Ron Powell & Associate LLC, a licensed insurance agency based in Norman OK. We represent multiple Insurance companies offering life, health, Medicare Supplements, Medicare Advantage HMO, PPO, stand alone prescription drug, dental plans and annuities. Medicare supplement plans are not connected with or endorsed by the federal government or the federal Medicare program. The purpose of this website is to educate consumers and for the solicitation of insurance products.opyright © 2021 Network Solutions, LLC. All rights reserved.

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