Group Census Form Company NameContact Person DetailsPrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Last Name *Street Address *City *State/Province *ZIP / Postal Code *Email Address *Phone Number *Proposed Effective Date:Current Carrier *Current Renewal Date:Company Structure: *Sole ProprietorCorporation LLCPartnershipOtherOther Company StructureType of Business:More than one location?YesNoNumber of Full Time Employee's (30+ hours/ week)How many weeks payroll?# of Cobra's:Costs to be paid by Employer:Please enter the costs % or $ amount to be paid by Employer:% or $ amount of Employee Costs% or $ amount of Dependent CostsTypes of Employees to be quoted:AllManagementHourlySalaryNon-UnionEmployees Living Out of State:YesNoIndustry SIC Code:Are you interested in other products?LifeDentalVisionLTDKnown Medical Conditions: (please describe)0 / 180Number of EmployeesBetween 1 to 50Field GroupEmployee NameSelectMaleFemaleDiverseAge/DOBSpouse (Y/N)YesNo# of ChildrenZipCOBRAYesNoAdd itemRemove itemSubmit Census Click here to download the General Census Spreadsheet. You can fill it up and send by email to info@solidhealthinsurance.com
