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Census Data Sheet

 
This information will be used to obtain quotes for group health insurance coverage.
To get an accurate quote please furnish all requested information and list any known medical
conditions or medications taken by anyone to be included on the insurance plan.
       
 
 
 
 
 
 
 
 
 
Requested Effective Date
 
 
 
 
 
 
 
 
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  Coverage* Needed
E=Employee Only
ES=Employee & Spouse Only
EC=Employee & Child(ren) Only
FF=Full Family Coverage
Medical Conditions (Indicate employee #) Employee #
   
   
   
   
   
           
             
       

 

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