Group Census 20 or less employees<\/a><\/p>\nGroup Census 100 or less Employees<\/a><\/p>\nGroup Census 200 or less Employees<\/a><\/p>\n\n <\/a>\n \n <\/span>\n <\/div>\n Group Health Benefits<\/h2>Employee Census<\/div><\/li><\/li>Effective Date:<\/label>\n \n <\/div>\n <\/li>Return to:<\/b> Vikki Sims, CIOP, CIC, CRM\nWilson, Washburn & Forster Insurance\nPhone: <\/b> 786-454-8402\nFax: <\/b> 786-454-8402\nE-mail:<\/b> vsims@wwfins.com\n<\/li>Census Information<\/h2><\/li>Contact Person:<\/label><\/div><\/li>Company:<\/label><\/div><\/li>Address<\/label> \n \n \n \n Street Address<\/label>\n <\/span>\n \n City<\/label>\n <\/span>\n \n ZIP \/ Postal Code<\/label>\n <\/span>\n <\/div>\n <\/div><\/li>Phone Number:<\/label><\/div><\/li>Fax:<\/label><\/div><\/li>Current Health Insurance Provider :<\/label><\/div><\/li>Current Deductible \/ Co-insurance %:<\/label><\/div><\/li>Desired Deductible:<\/label><\/div><\/li>Desired Co-Insurance %:<\/label><\/div><\/li>Program of Interest:<\/label>HMO<\/label><\/li>PPO<\/label><\/li><\/ul><\/div><\/li>Program of Interest:<\/label>POS (Combo HMO and PPO)<\/label><\/li>Dental & Vision<\/label><\/li><\/ul><\/div><\/li>Employee Information<\/h2>Employee 1<\/div><\/li>Name<\/label>\n \n \n \n First<\/label>\n <\/span>\n \n \n \n Last<\/label>\n <\/span>\n \n <\/div><\/li>DOB<\/label>\n \n MM<\/label>\n <\/div>\n \n DD<\/label>\n <\/div>\n \n YYYY<\/label>\n <\/div>\n <\/div><\/div><\/li>Age:<\/label><\/div><\/li>Sex:<\/label>Choose an Option<\/option>M<\/option>F<\/option><\/select><\/div><\/li>Home Zip:<\/label><\/div><\/li>Coverage<\/label>Choose an Option<\/option>EE - Employee Only<\/option>ES - Employee and Spouse<\/option>EC - Employee and Child(ren)<\/option>FA - Family<\/option>NA - Not taking insurance<\/option>Waive - Ins w\/ Spouce or Parents<\/option>ML - Ins w\/ Military<\/option><\/select><\/div><\/li>Employee 2<\/h2><\/li>Name<\/label>\n \n \n \n First<\/label>\n <\/span>\n \n \n \n Last<\/label>\n <\/span>\n \n <\/div><\/li>DOB<\/label>\n \n MM<\/label>\n <\/div>\n \n DD<\/label>\n <\/div>\n \n YYYY<\/label>\n <\/div>\n <\/div><\/div><\/li>Age:<\/label><\/div><\/li>Sex:<\/label>Choose an Option<\/option>M<\/option>F<\/option><\/select><\/div><\/li>Home Zip:<\/label><\/div><\/li>Coverage<\/label>Choose an Option<\/option>EE - Employee Only<\/option>ES - Employee and Spouse<\/option>EC - Employee and Child(ren)<\/option>FA - Family<\/option>NA - Not taking insurance<\/option>Waive - Ins w\/ Spouce or Parents<\/option>ML - Ins w\/ Military<\/option><\/select><\/div><\/li>Employee 3<\/h2><\/li>Name<\/label>\n \n \n First<\/label>\n <\/span>\n \n \n Last<\/label>\n <\/span>\n <\/div>\n <\/div><\/li>DOB<\/label>\n \n MM<\/label>\n <\/div>\n \n DD<\/label>\n <\/div>\n \n YYYY<\/label>\n <\/div>\n <\/div><\/div><\/li>Age:<\/label><\/div><\/li>Sex:<\/label>Choose an Option<\/option>M<\/option>F<\/option><\/select><\/div><\/li>Home Zip:<\/label><\/div><\/li>Coverage<\/label>Choose an Option<\/option>EE - Employee Only<\/option>ES - Employee and Spouse<\/option>EC - Employee and Child(ren)<\/option>FA - Family<\/option>NA - Not taking insurance<\/option>Waive - Ins w\/ Spouce or Parents<\/option>ML - Ins w\/ Military<\/option><\/select><\/div><\/li>\n <\/ul><\/div>\n
Group Census 100 or less Employees<\/a><\/p>\nGroup Census 200 or less Employees<\/a><\/p>\n\n <\/a>\n \n <\/span>\n <\/div>\n Group Health Benefits<\/h2>Employee Census<\/div><\/li><\/li>Effective Date:<\/label>\n \n <\/div>\n <\/li>Return to:<\/b> Vikki Sims, CIOP, CIC, CRM\nWilson, Washburn & Forster Insurance\nPhone: <\/b> 786-454-8402\nFax: <\/b> 786-454-8402\nE-mail:<\/b> vsims@wwfins.com\n<\/li>Census Information<\/h2><\/li>Contact Person:<\/label><\/div><\/li>Company:<\/label><\/div><\/li>Address<\/label> \n \n \n \n Street Address<\/label>\n <\/span>\n \n City<\/label>\n <\/span>\n \n ZIP \/ Postal Code<\/label>\n <\/span>\n <\/div>\n <\/div><\/li>Phone Number:<\/label><\/div><\/li>Fax:<\/label><\/div><\/li>Current Health Insurance Provider :<\/label><\/div><\/li>Current Deductible \/ Co-insurance %:<\/label><\/div><\/li>Desired Deductible:<\/label><\/div><\/li>Desired Co-Insurance %:<\/label><\/div><\/li>Program of Interest:<\/label>HMO<\/label><\/li>PPO<\/label><\/li><\/ul><\/div><\/li>Program of Interest:<\/label>POS (Combo HMO and PPO)<\/label><\/li>Dental & Vision<\/label><\/li><\/ul><\/div><\/li>Employee Information<\/h2>Employee 1<\/div><\/li>Name<\/label>\n \n \n \n First<\/label>\n <\/span>\n \n \n \n Last<\/label>\n <\/span>\n \n <\/div><\/li>DOB<\/label>\n \n MM<\/label>\n <\/div>\n \n DD<\/label>\n <\/div>\n \n YYYY<\/label>\n <\/div>\n <\/div><\/div><\/li>Age:<\/label><\/div><\/li>Sex:<\/label>Choose an Option<\/option>M<\/option>F<\/option><\/select><\/div><\/li>Home Zip:<\/label><\/div><\/li>Coverage<\/label>Choose an Option<\/option>EE - Employee Only<\/option>ES - Employee and Spouse<\/option>EC - Employee and Child(ren)<\/option>FA - Family<\/option>NA - Not taking insurance<\/option>Waive - Ins w\/ Spouce or Parents<\/option>ML - Ins w\/ Military<\/option><\/select><\/div><\/li>Employee 2<\/h2><\/li>Name<\/label>\n \n \n \n First<\/label>\n <\/span>\n \n \n \n Last<\/label>\n <\/span>\n \n <\/div><\/li>DOB<\/label>\n \n MM<\/label>\n <\/div>\n \n DD<\/label>\n <\/div>\n \n YYYY<\/label>\n <\/div>\n <\/div><\/div><\/li>Age:<\/label><\/div><\/li>Sex:<\/label>Choose an Option<\/option>M<\/option>F<\/option><\/select><\/div><\/li>Home Zip:<\/label><\/div><\/li>Coverage<\/label>Choose an Option<\/option>EE - Employee Only<\/option>ES - Employee and Spouse<\/option>EC - Employee and Child(ren)<\/option>FA - Family<\/option>NA - Not taking insurance<\/option>Waive - Ins w\/ Spouce or Parents<\/option>ML - Ins w\/ Military<\/option><\/select><\/div><\/li>Employee 3<\/h2><\/li>Name<\/label>\n \n \n First<\/label>\n <\/span>\n \n \n Last<\/label>\n <\/span>\n <\/div>\n <\/div><\/li>DOB<\/label>\n \n MM<\/label>\n <\/div>\n \n DD<\/label>\n <\/div>\n \n YYYY<\/label>\n <\/div>\n <\/div><\/div><\/li>Age:<\/label><\/div><\/li>Sex:<\/label>Choose an Option<\/option>M<\/option>F<\/option><\/select><\/div><\/li>Home Zip:<\/label><\/div><\/li>Coverage<\/label>Choose an Option<\/option>EE - Employee Only<\/option>ES - Employee and Spouse<\/option>EC - Employee and Child(ren)<\/option>FA - Family<\/option>NA - Not taking insurance<\/option>Waive - Ins w\/ Spouce or Parents<\/option>ML - Ins w\/ Military<\/option><\/select><\/div><\/li>\n <\/ul><\/div>\n
Group Census 200 or less Employees<\/a><\/p>\n\n <\/a>\n \n <\/span>\n <\/div>\n Group Health Benefits<\/h2>Employee Census<\/div><\/li><\/li>Effective Date:<\/label>\n \n <\/div>\n <\/li>Return to:<\/b> Vikki Sims, CIOP, CIC, CRM\nWilson, Washburn & Forster Insurance\nPhone: <\/b> 786-454-8402\nFax: <\/b> 786-454-8402\nE-mail:<\/b> vsims@wwfins.com\n<\/li>Census Information<\/h2><\/li>Contact Person:<\/label><\/div><\/li>Company:<\/label><\/div><\/li>Address<\/label> \n \n \n \n Street Address<\/label>\n <\/span>\n \n City<\/label>\n <\/span>\n \n ZIP \/ Postal Code<\/label>\n <\/span>\n <\/div>\n <\/div><\/li>Phone Number:<\/label><\/div><\/li>Fax:<\/label><\/div><\/li>Current Health Insurance Provider :<\/label><\/div><\/li>Current Deductible \/ Co-insurance %:<\/label><\/div><\/li>Desired Deductible:<\/label><\/div><\/li>Desired Co-Insurance %:<\/label><\/div><\/li>Program of Interest:<\/label>HMO<\/label><\/li>PPO<\/label><\/li><\/ul><\/div><\/li>Program of Interest:<\/label>POS (Combo HMO and PPO)<\/label><\/li>Dental & Vision<\/label><\/li><\/ul><\/div><\/li>Employee Information<\/h2>Employee 1<\/div><\/li>Name<\/label>\n \n \n \n First<\/label>\n <\/span>\n \n \n \n Last<\/label>\n <\/span>\n \n <\/div><\/li>DOB<\/label>\n \n MM<\/label>\n <\/div>\n \n DD<\/label>\n <\/div>\n \n YYYY<\/label>\n <\/div>\n <\/div><\/div><\/li>Age:<\/label><\/div><\/li>Sex:<\/label>Choose an Option<\/option>M<\/option>F<\/option><\/select><\/div><\/li>Home Zip:<\/label><\/div><\/li>Coverage<\/label>Choose an Option<\/option>EE - Employee Only<\/option>ES - Employee and Spouse<\/option>EC - Employee and Child(ren)<\/option>FA - Family<\/option>NA - Not taking insurance<\/option>Waive - Ins w\/ Spouce or Parents<\/option>ML - Ins w\/ Military<\/option><\/select><\/div><\/li>Employee 2<\/h2><\/li>Name<\/label>\n \n \n \n First<\/label>\n <\/span>\n \n \n \n Last<\/label>\n <\/span>\n \n <\/div><\/li>DOB<\/label>\n \n MM<\/label>\n <\/div>\n \n DD<\/label>\n <\/div>\n \n YYYY<\/label>\n <\/div>\n <\/div><\/div><\/li>Age:<\/label><\/div><\/li>Sex:<\/label>Choose an Option<\/option>M<\/option>F<\/option><\/select><\/div><\/li>Home Zip:<\/label><\/div><\/li>Coverage<\/label>Choose an Option<\/option>EE - Employee Only<\/option>ES - Employee and Spouse<\/option>EC - Employee and Child(ren)<\/option>FA - Family<\/option>NA - Not taking insurance<\/option>Waive - Ins w\/ Spouce or Parents<\/option>ML - Ins w\/ Military<\/option><\/select><\/div><\/li>Employee 3<\/h2><\/li>Name<\/label>\n \n \n First<\/label>\n <\/span>\n \n \n Last<\/label>\n <\/span>\n <\/div>\n <\/div><\/li>DOB<\/label>\n \n MM<\/label>\n <\/div>\n \n DD<\/label>\n <\/div>\n \n YYYY<\/label>\n <\/div>\n <\/div><\/div><\/li>Age:<\/label><\/div><\/li>Sex:<\/label>Choose an Option<\/option>M<\/option>F<\/option><\/select><\/div><\/li>Home Zip:<\/label><\/div><\/li>Coverage<\/label>Choose an Option<\/option>EE - Employee Only<\/option>ES - Employee and Spouse<\/option>EC - Employee and Child(ren)<\/option>FA - Family<\/option>NA - Not taking insurance<\/option>Waive - Ins w\/ Spouce or Parents<\/option>ML - Ins w\/ Military<\/option><\/select><\/div><\/li>\n <\/ul><\/div>\n