Employee Census
Group Name: ______________________________________________
Address: _____________________________________________________
Nature of Business: ______________________________________
Effective Date: ____________________________
Current Carrier Info: _______________________________________________
PPO Network __________________ Deductible _______________________
Dr. Copay _____RX ________________ Coinsurance______________________
Please answer the following questions to the best of your knowledge for anyone to be covered. If you answer
YES to any question, please explain in full with dates of service, health condition, doctor, and prognosis.
Claims over $5000 in the past 2 years: _________________________________________
Pregnancies: _______________________________________
Chronic Conditions: (Cancer, Heart Disease, Diabetes, Substance Abuse, Mental Illness,
AIDS or any Immune Deficiency Disease, Spina Bifidia, Kidney Disease, Cystic Fibrosis
or any other Progressive Disabling Condition) If YES, circle and provide details.
Pending hospitalizations, surgery, or other treatments: ___________________________
Is the # of
Employee DOB or Spouse being Spouse's Children
Number Name M/F Age covered? DOB or Age being covered?
updated 2/5/07