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Click here to provide us with census information to find out.

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Complete A Benefits Census

Please take a few minutes to complete this Benefit Census and provide us the information necessary to quote to you benefit options and prices that best fit your needs.

Your Information is submitted securely. We respect your privacy.



Benefits Census: (Company Information)

Company:*			Industry?
Address:*			City:*

State:*			Phone:*

Contact Name:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 1:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 2:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire:

Medical Coverage:

Dental Coverage:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 3:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire:

Medical Coverage:

Dental Coverage:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 4:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire:

Medical Coverage:

Dental Coverage:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 5:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire:

Medical Coverage:

Dental Coverage:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 6:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire:

Medical Coverage:

Dental Coverage:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 7:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire:

Medical Coverage:

Dental Coverage:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 8:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire:

Medical Coverage:

Dental Coverage:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 9:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 10:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire:

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 11:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire:

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 12:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 13:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 14:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 15:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 16:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 17:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 18:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 19:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

Skip To Next Section | Back To Top

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Employee Information - Please complete this section for each employee. If you have more than 20 listings, please call 508.285.0801.

Benefits Census - Employee 20:

Full Name:

Male or Female?

Male

Female

Zip Code:

State:

Occupation:

Date Of Birth:

Date Of Hire

Medical Coverage:

Dental Coverage:

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Benefits Census - Current Health Plan:

Carrier?

Individual rates:

Family Rate

Co-Pay:

Deductible:

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Benefits Census - Current Dental Plan:

Carrier?

Individual rates:

Family Rate

Co-Pay:

Deductible:

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Benefits Census - Life / Accidental Death & Dismemberment:

Current Life / AD&D Carrier:

Costs:

Rate per $1000.00

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Benefits Census - Long Term Disability:

Current LTD Carrier:

Costs:

Rate per $100.00

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Benefits Census - Short Term Disability:

Current STD Carrier:

Costs:

Rate per $10.00

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Benefits Census - Worker Compensation:

Current WC Carrier:

Costs:

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Thank you for taking the time to complete our Benefits Census. If you are experiencing difficulty using this form or have questions please email BenefitSupport@HR Knowledge.com or call 508.285.0801. Otherwise, please submit your information and a representative will contact you shortly.

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