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KOSS benefits Financial & Insurance Services
EMPLOYEE CENSUS
Please fill out this Employee Census form
Name of Company:
Nature of Business:
Contact Person:
City/State/Zip Code:
Phone Number:
Fax Number:
Current Carrier:
Renewal Date:
Type Of Plan:
Choose from the list below
Current Premium
Single Employee:
Employee/Spouse:
Employee/Child:
Employee/2 or more Children:
Employee/Spouse/Children:
Employee 1
Name:
Sex:
Male
Female
Date Of Birth:
Family Status:
Choose from the list below
Employee 2
Name:
Sex:
Male
Female
Date Of Birth:
Family Status:
Choose from the list below
Employee 3
Name:
Sex:
Male
Female
Date Of Birth:
Family Status:
Choose from the list below
Employee 4
Name:
Sex:
Male
Female
Date Of Birth:
Family Status:
Choose from the list below
Employee 5
Name:
Sex:
Male
Female
Date Of Birth:
Family Status:
Choose from the list below
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