Health Census

Company Name: ____________________________   Phone: ____________________________
Address: ____________________________   Fax: ____________________________
City, State, Zip: ____________________________   Contact: ____________________________
Type of Business or Industry: ____________________________   Email: ____________________________
Current Health Company: ____________________________   Renewal Date: ____________________________
Current Premium: ____________________________   SIC Code: ____________________________
Current Plan Design (circle): Deductible: 0 500 1,000 1,500 2,500 5,000   Co-Insurance: 100% 90% 80%
Current Employee Benefits (circle): Dental/Eye Care 401K Disability Group Life Cafe/Section 125
Also interested In (circle): Dental/Eye Care 401K Disability Group Life Cafe/Section 125
  Employee Name Gender
(M/F)
Age Spouse
Age
# of
Children
Home
Zip Code
Type*
1              
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3              
4              
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15              

 

 

*Type: ee- employee only es – employee & spouse ec – employee & children fam – family

** Do any employees listed work at a different location or different state? Yes No If Yes, note proper Zip Code

Medical Questions :

  1. Are any employees or dependents currently pregnant? Yes No
  2. Has anyone been confined to a hospital in the past 24 months? Yes No
  3. Are any employees currently disabled? Yes No
  4. Are any employees on COBRA or State Continuation? Yes No
  5. Has anyone received treatment for cancer, stroke, diabetes, psychological/alcohol/drug
    treatments and/or disorder of the heart/kidney/immune system? Yes No
    If “Yes” give details: ___________________________________________________________________________

Please complete and fax to 636-349-0402