Thank you for choosing FBN Health and Mike Keith Insurance as your trusted insurance broker. You have indicated that your business has more than 10 employees. If so, good news, your employees don’t have to fill out individual health statements! Please complete the fields below and upload a copy of your employee census using the form below.

Have more questions? Please click here to schedule an appointment with our FBN sales rep or call 877-892-3303

If you do not have an employee census, use the link below to download a blank census to fill out and upload.

Download Blank Census
FBN Form
Name
Name
First
Last
Maximum upload size: 516MB

Note: If you have fewer than 10 employees, please use the eHealth link sent in the original email to start the application process