Business Group Census Form

Please fill out the Business Group Census form below. If you wish, you may also download the form by clicking here.
All fields marked with ( * ) are required.


Company Name*:
Address*:
City*:
State*:
Zip Code*:
Phone*:
Fax:
Contact Name*:
Email*:
Nature of Business*:
Number of Employees*:

  

  

Employee Name:
Age or Date of Birth:
Gender:
Coverage:

E   =Employee Only
ES =Employee + Spouse
EC =Employee + Children
EF =Employee + Family
Zip Code:






Please Enter the letters or numbers you see in the box.
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Click on the "Submit Group Census Information" button below to send your
Florida Business Group Census Form.



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Innovative insurance offers the following Business/Commercial Insurance products: General Liability Insurance, Workers Comp Insurance, Construction Insurance, Business Insurance, and Commercial Auto. For Personal Insurance, we offer: Auto and Homeowners Insurance. From our office in Coral Springs, Florida, we serve Ft. Lauderdale and all surrounding cities, Palm Beach County, and the rest of South Florida. Our address is 5461 N. University Drive, Suite#103 Coral Springs, FL 33067. Our phone number is (954) 340-9551.