Sihle Insurance Group | Central Florida Insurance Agency - Offering Commercial Insurance, and Personal Insurance Coverage. Serving Greater Orlando and Jacksonville areas.

If you are interested in applying for our 1-50 employee group coverage, please complete the census below. We will use this information to determine the best service plan for your company.

If you would prefer to complete your census offline and email it in, please click the download line below. Complete the census and email it to back to us at census@sihle.com.

Download Census Form

Required fields are marked with a blue asterisk (*).
Business Name:	*
Contact Name:	*
Street Address 1:	*
Street Address 2:
City:	*	State:	*
		Zip:	*
Phone:	*	Fax:
Email Address:
Requested Effective Date:
Agent Name:
Industry / SIC Code:
# Of Years In Business:		# Of Locations:
Current Carrier:
How Long:
Current Plan Design:
Employer Contribution	EE:		DEP:

Last Name

First Name

M/F

D.O.B

D.O.H

Home Zip

Coverage

Please tell us about the employees in your company. Reference the following legend for explanation of codes:

D.O.B
D.O.H.
M/F
EE
ES
EC

Date of Birth
Date of Hire
Male or Female
Employee Only
Employee/Spouse
Employee/Child

ESC
COBRA
WP
OC
DECLINE

Family
COBRA
Waiting Period
Other Coverage
Decline-no reason