Web Page Census 9.26.2019

                  Employee Census Form

M & M Insurance Agency, Inc    1685 S. Colorado Blvd Suite # S312    Denver Colorado 80222-4040
 Phone: 303-988-2115     Fax:   303-578-2115       
Email: info@mminsuranceagency.com

     


Company Name:

Address:
City, State and Zip:
Current Carrier:
Proposed Effective Date:
Company Contact:
Phone:
Fax Number:


GROUP INFORMATION  

 

Please list all current employees on your payroll. Indicate each employee’s eligibility for coverage, including those employees waiving coverage.
If married employees plan to enroll separately, please list them separately, and indicate how many children each employee intends to enroll as dependents.

If the enrollment code selected is 03 or 04, you must indicate the ages of all dependent children.
If not, we will assume two children ages 10 and 20, and the rates may be incorrect.
If the enrollment code selected is 02 or 03, you must indicate the age and gender of the spouse or domestic partner.
If not, we will assume the spouse’s age is the same as the employee and gender is opposite, and the rates may be incorrect.

We will re-rate new groups based on actual enrollment and adjust the rates accordingly.

Note: “Current employee” includes owners, sole proprietors, partners of a partnership, or independent contractors
If an employer/employee relationship exists and employee is reported on payroll as receiving a wage or commission.
Employees who work on a seasonal, temporary, or substitute basis are not eligible and should not be included in the census.

Employee name

Date of birth MM/DD/YY

Gender

Hours per week

Hire date

Eligible for coverage

Employee ZIP code

Enrollment code(see key)

Spouse or domestic partner

Ages of all dependents

DOB

Gender

1

 

M   F

 

 

Y   N

 

 

 

M   F

 

2

 

M   F

 

 

Y   N

 

 

 

M   F

 

3

 

M   F

 

 

Y   N

 

 

 

M   F

 

4

 

M   F

 

 

Y   N

 

 

 

M   F

 

5

 

M   F

 

 

Y   N

 

 

 

M   F

 

6

 

M   F

 

 

Y   N

 

 

 

M   F

 

7

 

M   F

 

 

Y   N

 

 

 

M   F

 

8

 

M   F

 

 

Y   N

 

 

 

M   F

 

9

 

M   F

 

 

Y   N

 

 

 

M   F

 

10

 

M   F

 

 

Y   N

 

 

 

M   F

 

11

 

M   F

 

 

Y   N

 

 

 

M   F

 

12

 

M   F

 

 

Y   N

 

 

 

M   F

 

 Enrollment code key    Family enrollment status    Other status

1.      Employee only    G    Waiving due to other comparable coverage

2.      Employee + spouse    NP Has not served waiting period

3.      Employee + spouse + child(ren)    NH Not enough hours to qualify for coverage/class not eligible

4.      Employee + child(ren)    W    Waiving to no other coverage

M & M INsurance Agency Dental Coverage

M & M Insurance Agency Employee Census<
Name of Firm: Contact Person:
Phone Number: Email address:
Address: Coverage Codes: E = Employee Only E-1 = Employee + Spouse E-2 = Employee + Child(ren) E-3 = Employee + Spouse + Child(ren)
Name Sex M/F Date of Birth Spouses DOB # of Children Residence ZIP Code Coverage Code
Last, First, Mid. Initial Month Day Year
1
2
3
4
5
6
7
8
9
10
11
12