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Employee Census Form - uniproinsurance.com

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Employee Census Form - uniproinsurance.com Powered By Docstoc
					                                      Unipro Insurance Services
                                      3129 S. Hacienda Blvd. Suite 308, Hacienda Heights, CA 91745
                                      Tel: 626-373-3043              Fax: 626-968-0505

                                                      Employee Census Form
Company Name:
Company Address:
Contact Person:
Telephone Number:                                                                Fax Number:
Email Address:
Desired Effective Date:                                                          Renewal Date:                      RAF:
Existing Medical Insurance Company:                                              Plan Name:
Existing Dental Insurance Company:                                               Plan Name:
Monthly Premium:

                                                      Gender     Date of Birth                               Coverage for
Name of Employee                                                                  Home Zip Code
                                                       M/F       mm/dd/yyyy                       Employee     Spouse       Children
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Additional Information:




                             Upon completion, please e-mail the census to us at: info@uniproinsurance.com
                                                  or fax to us at 626-968-0505

				
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