Insuring your Future!

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NEW GROUP FORMS
Company Quote Information
Employee Health Questionnaire
Employee Census Data

CENSUS FORMS
1. Census - Life, Dental, Health, Disability
2. Census - Life & Health Only
3. Census - Dental Only

OTHER FORMS
Company Information
Agent of Record SAMPLE LETTER
Group Cancellation SAMPLE LETTER
Supply Request Form

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Clemons Agency
P O Box 599
324 Commerce Street
Hawkinsville, Ga. 31036

478-783-1661
478-783-1660 (FAX)