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Bridgeport Professional Center
900 Madison Avenue
2nd Floor - Suite 212
Bridgeport, CT 06606
Telephone: (203) 367-9600
Trumbull Professional Center
115 Technology Drive
3rd Floor - Suite B-306
Trumbull, CT 06611
Toll Free: 855-4FRAZAO
Victor Frazao
Antonio Paulo Pinto
Maria Ines Dias
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Contact Information
Group Name:
Telephone:
Group Contact:
Fax:
Group Address:
City, State & Zip:
E-Mail Address:
Current Health Carrier:
Effective Date:
# of employess:
Cobra Employees
How long in business:
Worker's Compensation?:
Employees in waiting period:
Group Census
(If More Than 10 Employees, please call us to receive
a large group census form.)
Employee #
Birth Date (mm/dd/yy)
Gender
Zip Code
Select Coverage
# 1
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 2
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 3
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 4
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 5
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 6
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 7
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 8
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 9
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 10
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
Additional Comments
Please give any additional comments or questions
No coverage of any kind is bound or implied by submitting information via this online form
We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
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