Group Health Benefits: Group Census 20 or less employees Group Census 100 or less Employees Group Census 200 or less Employees Group Health BenefitsEmployee CensusEffective Date: Return to: Vikki Sims, CIOP, CIC, CRM Wilson, Washburn & Forster Insurance Phone: 786-454-8402 Fax: 786-454-8402 E-mail: vsims@wwfins.com Census InformationContact Person:Company:Address Street Address City ZIP / Postal Code Phone Number:Fax:Current Health Insurance Provider :Current Deductible / Co-insurance %:Desired Deductible:Desired Co-Insurance %:Program of Interest:HMOPPOProgram of Interest:POS (Combo HMO and PPO)Dental & VisionEmployee InformationEmployee 1Name First Last DOB MM DD YYYY Age:Sex:Choose an OptionMFHome Zip:CoverageChoose an OptionEE - Employee OnlyES - Employee and SpouseEC - Employee and Child(ren)FA - FamilyNA - Not taking insuranceWaive - Ins w/ Spouce or ParentsML - Ins w/ MilitaryEmployee 2Name First Last DOB MM DD YYYY Age:Sex:Choose an OptionMFHome Zip:CoverageChoose an OptionEE - Employee OnlyES - Employee and SpouseEC - Employee and Child(ren)FA - FamilyNA - Not taking insuranceWaive - Ins w/ Spouce or ParentsML - Ins w/ MilitaryEmployee 3Name First Last DOB MM DD YYYY Age:Sex:Choose an OptionMFHome Zip:CoverageChoose an OptionEE - Employee OnlyES - Employee and SpouseEC - Employee and Child(ren)FA - FamilyNA - Not taking insuranceWaive - Ins w/ Spouce or ParentsML - Ins w/ Military
