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Group Census Form
Group Census Form
Company Name
*
Contact Name
*
Full Address
*
Email
*
Telephone
*
Proposed Effective Date
*
Current Carrier
Current Renewal Date
Company Structure
Select one
Sole Proprietor
Corporation LLC
Partnership
Other
Type of Business
More than one location?
Select one
Yes
No
Number of Full Time Employee's (30+ hours/ week)
Total Number of Employees
Payroll Cycle
# of Cobra's
% of costs to be paid by Employer
% of Employee Costs
% of Dependent Costs
Types of Employees to be quoted
Select one
All
Management
Hourly
Salary
Non-Union
Employees Living Out of State
Select one
Yes
No
Industry SIC Code
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