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Census Form
Census Information For: Effective Date:
(mm/dd/yy)
Business Type: SIC Code:
Group Address:
Street Address:
 State:
 zip:
Agent Name: Date:
(mm/dd/yy)
Fill out multiple employees' information below and click submit.
Gender Date of Birth Coverages
M = Male
F = Female		 mm = Month as 2 digits (eg. 05)
dd = Day as 2 digits (eg. 21)
yyyy = Year as 4 digits (eg. 1955)		 S = Single
H = Husband/Wife - 2 Party
P = Parent/Child - 2 Party
N = Parent/Children
F = Family
Census Information
Employee Gender
M or F		 Age Date of Birth
mm/dd/yyyy		 Coverage
S,H,P,N,F		 ZIP code
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Employee Gender
M or F		 Age Date of Birth
mm/dd/yyyy		 Coverage
S,H,P,N,F		 ZIP code
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Employee Gender
M or F		 Age Date of Birth
mm/dd/yyyy		 Coverage
S,H,P,N,F		 ZIP code
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Employee Gender
M or F		 Age Date of Birth
mm/dd/yyyy		 Coverage
S,H,P,N,F		 ZIP code
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Employee Gender
M or F		 Age Date of Birth
mm/dd/yyyy		 Coverage
S,H,P,N,F		 ZIP code
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