Group Health Census Group Health Census
Company Name:
Contact:
Address:
City:
State:   Zip: 
Daytime Phone: ( )
Total # of Employees:
Nature of Business:
Employer Contribution:
Email:
Effective Date:
(mm-dd-yyyy)
 
SIC Code :  
Plans:  
EE-Employee Only; ES-Employee/Spouse;
EC-Employee/Child; FA-Family
 
NAME
AGE
D-O-B
(mm-dd-yyyy)
1-MALE
2-FEMALE


1-EE
2-ES
3-EC
4-FA
1-Unknown
2-PPO
3-HMO
County of Residence
  SAMPLE
35
1-20-1965
2
1
3
Palm Beach
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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25
26
27
28
29
30
31
32
33
34
35
36
37
38
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40
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44
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46
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48
49
50

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