Census for Group Short Term Disability
COMPANY
Name:
City:
Zip:
(Please be specific)
Phone:
PLAN DESIGN
Elimination Period
0 / 7 Days 1 / 8 Days 1 / 15 Days 15 / 15 Days 30 / 30 Days
Benefit Period
13 Weeks 26 Weeks 52 Weeks
Income Benefit
60% $200 $300 $400 $500 Other
EMPLOYEE CENSUS
Name
Sex
DOB
Monthly Income
Job Description
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:
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