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Third Generation since 1932,
serving personal and
business insurance in
the tri-state area.

Small Group 1-49 Employee Census

When completing the census information for your employees, each dependent that will be enrolled must be listed with their birthdate.
Employer Information
Company Name: *
Contact Name: *
Contact Email: *
Contact Phone:
Current Insurance Co
Number of Employees
Employee Information
  Name Date of Birth Sex Employee or Dependent ? Smoker or Non Smoker Date Employed Zip Code
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* = Required Field