Download Census Form

Get a Quote

Step 1

COMPLETE THE GROUP CENSUS FORM IN BLUE OR BLACK INK.

Please include the desired plan design and the carriers you want quoted.

If you have any questions, or you are not sure how to fill out the census form, simply contact Southern Utah Insurance.

Phone: 435-673-7912 or Fax: 435-634-9277

Step 2

Make sure the employees that you are listing on the census form are all full time employees working more than 30 hours a week. Please put a star by your out of state employees. Employees waiving coverage due to other group coverage will not be counted towards your group’s participation. Please call our office to find out if your 1099 employees will be eligible for group coverage.

Step 3

FAX THE COMPLETED CENSUS FORMS TO: 435-634-9277

We will be in contact with you upon receipt of your completed census form. We will also keep you advised of the underwriting status.

We obtain carrier quotes from the following companies:

  • Select Health
  • Altius
  • Aetna
  • Humana
  • Regence BCBS of Utah
  • United Health Care
  • And Others.

If you have questions please contact our office at:

Southern Utah Insurance
1224 South River Road #A203
St. George, Utah 84790
Phone: 435-673-7912
FAX: 435-634-9277

Thank You.


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