Employer Group Survey/Census

Answer all the questions and submit the form.

 

  1. Name of Company:

  2. Contact person:

  3. Street Address:

  4. City, State, Zip:
    ,

  5. Phone:

  6. Email:



  7. Number of full-time employees:


  8. Are any eligible employees currently being treated for or have a history of any of the following conditions: diabetes, hypertension, elevated cholesterol, heart problems, ARC/AIDS? If yes, How many?


  9. Are any employees/dependent spouses pregnant?

    Yes No




    Benefits Requested
      (Check all that apply)

    Medical
    Dental
    Life*
    LTD*


    *Please provide occupations and annual income only if requesting these benefits.


    Request Effective Date:


     Name                                Age      Sex        Status       Occupation         Income

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McGlothlin Group.
Copyright © 2000 [McGlothlin Group]. All rights reserved.
Revised: November 15, 2001