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Mailing Response (Fields marked * are required fields)

         
  Company Name: *    
         
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Phone: * Fax:*  
         
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Employee Census
                   
  Employee Name / Smoker or Non Male or Female Date of
Birth
(mm-dd-
yyyy)
Type of Medical Coverage (see codes below) Spouse
DOB
(mm-dd-
yyyy)
Dates of Birth of Children
(mm-dd-
yyyy)
Residential Zip Code Household Yearly Salary  
                   
   
                   
   
                   
   
                   
 
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
   
                   
                 
                   
Coverage Codes for Medical:
EE = Employee Only
EC = Employee + Child(ren)
ES = Employee + Spouse
EF= Employee + Spouse and Child(ren)
W - Waived, not taking coverage





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