Census for Group Life
COMPANY
Name:
City:
Zip:
(Please be specific)
Phone:
PLAN DESIGN
Amount
10,000 25,000 50,000 Other
Buy up Option
90/10 80/20 70/30 50/50 Other
Dependant Life
5,000 10,000 15,000 20,000 Other
EMPLOYEE CENSUS
Use Only if Dependant Life
Name
Sex
DOB
Spouse DOB
# of Children
1
Male Female
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Comments or Questions: (Please include any pre-existing conditions and medications you are aware of.)
If you have more than 25 in a group, please send Excel listing to:
HOME CAFETERIA TERM DENTAL 401K LT DISABILITY ST DISABILITY HEALTH ACCIDENT Q & A ASK A QUESTION