Last First Sex Age or Zip Spouse No. of COBRA Life Only
Name Name (M/F) DOB Code (Y/N) Children (Y/N) (Y/N)
Instructions for completing template:
1. List each employee to be insured with the company health plan by last name, first name.
2. Complete Sex with M or F.
3. Input Date of Birth in ## / ## / #### format.
4. Indicate zip code where employee's home is located.
5. Indicate whether spouse will be include on policy, and if so, the Date of Birth of the Spouse.
6. Indicate the number of children to be covered on the plan.
7. If insured is on COBRA, then indicate Yes. If insured will be covered for Life Only, indicate Yes.
8. Save the template to an Excel spreadsheet. You may then email the spreadsheet to the email address below
or fax the completed template to me.
Fax: (831) 484-1058
If you have any questions, please call Eric Johnsen at (831) 214-0964.
Field Label Allowed Values
Last Name Last name of employee. Enter only letters and spaces.
First Name First name of employee. Enter only letters and spaces.
Sex (M/F) Gender of employee. Enter M or F. Blank means M.
Age or DOB Current age OR date of birth of employee. Enter a whole number for age or a date in the format of MM/DD/YYYY.
Zip Code Seven digit zip code of employee's home address. Blank defaults to Employer's Zip Code.
Include Spouse (Y/N) Enter Y or N indicating if the employee's spouse will be included. Blank means N.
No. of Children Enter a whole number indicating the number of children that will be covered for the employee. Blank means zero.
COBRA (Y/N) Enter Y or N indicating if the employee's status is COBRA or not. Blank means N.
Life Only (Y/N) Enter Y or N indicating if the employee will have life coverage only. Blank means N. COBRA cannot be Life Only.
PLEASE NOTE: Select Tools/Options/Edit and uncheck the Fixed Decimal Places box. When copying or
cutting and pasting census from another Excel file to the Census worksheet, please select Edit - Paste Special -