Census Form
Please Return to:
Fax: E-mail:
TODAY'S DATE: BROKER COMPANY:
GROUP NAME: BROKER CONTACT:
CITY: CURRENT CARRIER:
COUNTY: CURRENT PLAN TYPE:
STATE: OH SIC CODE:
ZIP CODE: EFFECTIVE DATE:
# OF EMPLOYEES: RETURN TO:
Spouse State besides
Name Sex DOB/Age S ES EC F MP MS W Child(ren)
DOB/Age Ohio
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
S = Single ES = Employee + Spouse EC = Employee + Child F = Family
KEY:
MP = Medicare Primary MS = Medicare Secondary W = Waiver
Medicare Primary (MP): If the group is under 20 employees. Any employee who is over the age of 65 will be covered by Medicare.
Medicare Secondary (MS): If the group is over 20 employees. Medicare will be secondary and will come after their elected coverage.