Thank you for choosing 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 sales rep or call 660-747-3151

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

FBN Form
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

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