Employee Census Form Questions?
Call Toll-Free (888) 474-6627
IMPORTANT - Before completing this form, please read the following information. The Employee Census Form asks for the following information:
- Employee Name (This entry may be blank, but the field cannot be omitted)
- Date of Hire (mm-dd-yyyy)
- Employee Home Zip Code
- Date of Birth (mm-dd-yyyy)
- Gender (Use M for Male, F for Female)
- Job Title (Use if LTD quote is desired)
- Annual Earnings (Use if LTD or Life quote is desired) (This must be NUMERIC)
- Family Status (EE=Single Employee, ES=Emp+Spouse, EC=Emp+Child(ren), EF=Family)
- Plan Participation (HMO, PPO or POS)
Submission of a census does not constitute existence of an employee benefits program. Additional information may be required. A representative will contact you to acknowledge receipt of your census and review the proposal process.