GROUP HEALTH INSURANCE - EMPLOYEE CENSUS
Contact Information:
Company Name:
Nature of Business:
Street Address:
City:
State:
Zip:
Daytime Phone:
Email Address:
Present Carrier:
Plan Type:
What Type of Benefits Do You Want? (press Ctrl while selecting multiples)
HMO (Default)
PPO
Dual Choice
Dental
Vision
Life ( Level benefit, based on salery or postion
Prescription Drugs
Disability
Indicate if you want a specific company quotes (Blue Cross, Kaiser, etc.)
Submit this form accordingly if you have more than 10 employees:
Full Time Employees
Part Time
Cobra
Decline
Emp. 1 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation
Emp. 2 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation
Emp. 3 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation
Emp. 4 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation
Emp. 5 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation
Emp. 6 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation
Emp. 7 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation
Emp. 8 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation
Emp. 9 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation
Emp. 10 Name
Male
Female
Age
Spouse Coverage
# of Children
Zip
Code
Date of
Hire
Salary or
Range
Occupation