Business Name *
Number of Full-Time Employees *
Current Health Insurance Carrier
Contact Name *
Contact Phone
Email *
Employee 1 - Name *
Employee 1 - Zip Code *
Employee 1 - Date of Birth or Age *
Employee 1 - Gender
Employee 1 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 2 - Name *
Employee 2 - Zip Code *
Employee 2 - Date of Birth or Age *
Employee 2 - Gender
Employee 2 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 3 - Name *
Employee 3 - Zip Code *
Employee 3 - Date of Birth or Age *
Employee 3 - Gender
Employee 3 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 4 - Name *
Employee 4 - Zip Code *
Employee 4 - Date of Birth or Age *
Employee 4 - Gender
Employee 4 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 5 - Name *
Employee 5 - Zip Code *
Employee 5 - Date of Birth or Age *
Employee 5 - Gender
Employee 5 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 6 - Name *
Employee 6 - Zip Code *
Employee 6 - Date of Birth or Age *
Employee 6 - Gender
Employee 6 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 7 - Name *
Employee 7 - Zip Code *
Employee 7 - Date of Birth or Age *
Employee 7 - Gender
Employee 7 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 8 - Name *
Employee 8 - Zip Code *
Employee 8 - Date of Birth or Age *
Employee 8 - Gender
Employee 8 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 9 - Name *
Employee 9 - Zip Code *
Employee 9 - Date of Birth or Age *
Employee 9 - Gender
Employee 9 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 10 - Name *
Employee 10 - Zip Code *
Employee 10 - Date of Birth or Age *
Employee 10 - Gender
Employee 10 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 11 - Name *
Employee 11 - Zip Code *
Employee 11 - Date of Birth or Age *
Employee 11 - Gender
Employee 11 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 12 - Name *
Employee 12 - Zip Code *
Employee 12 - Date of Birth or Age *
Employee 12 - Gender
Employee 12 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 13 - Name *
Employee 13 - Zip Code *
Employee 13 - Date of Birth or Age *
Employee 13 - Gender
Employee 13 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 14 - Name *
Employee 14 - Zip Code *
Employee 14 - Date of Birth or Age *
Employee 14 - Gender
Employee 14 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 15 - Name *
Employee 15 - Zip Code *
Employee 15 - Date of Birth or Age *
Employee 15 - Gender
Employee 15 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 16 - Name *
Employee 16 - Zip Code *
Employee 16 - Date of Birth or Age *
Employee 16 - Gender
Employee 16 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 17 - Name *
Employee 17 - Zip Code *
Employee 17 - Date of Birth or Age *
Employee 17 - Gender
Employee 17 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 18 - Name *
Employee 18 - Zip Code *
Employee 18 - Date of Birth or Age *
Employee 18 - Gender
Employee 18 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 19 - Name *
Employee 19 - Zip Code *
Employee 19 - Date of Birth or Age *
Employee 19 - Gender
Employee 19 - If spouse and/or child(ren) are to be covered, please list their ages
Employee 19 - If spouse and/or child(ren) are to be covered, please list their ages (copy)
Employee 20 - Name *
Employee 20 - Zip Code *
Employee 20 - Date of Birth or Age *
Employee 20 - Gender
Employee 20 - If spouse and/or child(ren) are to be covered, please list their ages
Is there is anything else you would like us to know before submitting your census?
