Employee Benefits Census

Primary Address

Additional Office Locations (if any)

Location 1:

Location 2:

Primary Contact Information

Additional Contact Information

Employee Structure & Payroll Information

Waiting Period for New Hires:

Current Coverage Information (If Applicable)

Medical Coverage

Dental Coverage

Vision Coverage

Life Coverage

STD Coverage

LTD Coverage

Worksite Coverage

Employee Census Detail

Please provide detailed information for all benefit-eligible employees, including those waiving coverage. List each employee (EE)

first, followed immediately by their spouse (SP) and any dependent children (CH). Use one row per individual.

LEGEND:

1. Member Type: EE = Employee, SP = Spouse, CH = Child/Dependent

2. Coverage Tiers: EO = Employee Only, ES = Employee + Spouse, EC = Employee + Child(ren), FAM = Family

3. Gender: M = Male, F = Female

4. Date Format: MM/DD/YYYY (e.g., 03/15/1985)

5. COBRA/Continuation: Y = Yes, N = No

6. Full-time Student: Y = Yes, N = No (for dependents over 18)

FILL OUT YOUR INFORMATION BELOW:

* Occupation and Earnings fields are optional but may be required for certain coverage types.

Please ensure all information is accurate and complete before submitting.