Haisha Insurance Services - Insurance License: 0794619
Group Census Form
Company Name:
Contact Name:
Address:
Email:
City:
State:
Zip:
Tel#:
Fax#:
Proposed Effective Date:
Current Carrier:
Type of Business:
# of Cobra's:
Industry SIC Code:
Group Term Life Insurance (Amount ):
Would you like Dental Insurance?:
Yes
No
Known Medical Conditions: (please describe)
Number of Employees
-
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EE#
EE Name
M/F
Age/DOB
Enrollment Status
Zip
#COBRA'S
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Employee & Spouse
Employee & Child(ren)
Employee, Spouse & Child(ren)
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No
3
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4
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5
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6
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7
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8
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9
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10
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11
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12
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13
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14
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15
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16
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17
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18
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19
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20
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21
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22
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23
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24
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25
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26
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27
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28
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29
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30
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31
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32
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33
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34
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35
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Employee & Child(ren)
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36
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Employee & Child(ren)
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37
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38
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39
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Employee & Child(ren)
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40
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Employee & Child(ren)
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41
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Employee & Child(ren)
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42
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Employee & Child(ren)
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43
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Employee & Child(ren)
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44
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Employee & Child(ren)
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45
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Employee & Child(ren)
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46
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Employee & Spouse
Employee & Child(ren)
Employee, Spouse & Child(ren)
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47
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Employee & Spouse
Employee & Child(ren)
Employee, Spouse & Child(ren)
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No
48
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Employee & Spouse
Employee & Child(ren)
Employee, Spouse & Child(ren)
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49
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Employee & Child(ren)
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50
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Employee & Child(ren)
Employee, Spouse & Child(ren)
Yes
No
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