EMPLOYEE CENSUS

COMPANY NAME:___________________________________________YRS IN BUS.____

ADDRESS:__________________________________________________________________

NATURE OF BUSINESS_________________________________PH#__________________

	EMPLOYEE NAME	AGE OR D.O.B.	SEX M/F	SPOUSE COVERED Y/N	# OF CHILDREN COVERED	HMO/PPO & Salary & Occ if LTD
1
2
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5
6
7
8
9
10
11
12

** PLEASE QUOTE HMO( ) PPO( ) DENTAL( ) LIFE( ) VISION( ) LTD( )