Confidential Employee Census
Company Name:
*
Company Mailing Address:
Street Address
Street Address Line 2
City
Province
Postal Code
Company Phone:
*
-
Area Code
Phone Number
Company Contact Name:
*
Contact Email Address:
*
example@example.com
Preferred Contact Method:
Phone | Email | Text Message
Do you currently have an insurer?
*
Please Select
Yes
No
Present Insurer:
Renewal date for current insurer
-
Month
-
Day
Year
Date
Have you been with your present insurer for less than 3 years?
Please Select
Yes
No
Name of previous insurer:
How many years were you with this insurer?
Are any employees presently not actively at work due to a disability?
*
Please Select
Yes
No
Please provide any extra details we may find helpful while quoting:
Employee details
*
Employee Name or Initials
Gender
Family/Single
Occupation
Date of Birth or Age
Earnings (if quoting for disability ONLY)
Hire Date
1
Female
Male
Other
Family
Single
2
Female
Male
Other
Family
Single
3
Female
Male
Other
Family
Single
4
Female
Male
Other
Family
Single
5
Female
Male
Other
Family
Single
6
Female
Male
Other
Family
Single
7
Female
Male
Other
Family
Single
8
Female
Male
Other
Family
Single
9
Female
Male
Other
Family
Single
10
Female
Male
Other
Family
Single
11
Female
Male
Other
Family
Single
12
Female
Male
Other
Family
Single
13
Female
Male
Other
Family
Single
14
Female
Male
Other
Family
Single
15
Female
Male
Other
Family
Single
16
Female
Male
Other
Family
Single
17
Female
Male
Other
Family
Single
18
Female
Male
Other
Family
Single
19
Female
Male
Other
Family
Single
20
Female
Male
Other
Family
Single
21
Female
Male
Other
Family
Single
22
Female
Male
Other
Family
Single
23
Female
Male
Other
Family
Single
24
Female
Male
Other
Family
Single
25
Female
Male
Other
Family
Single
26
Female
Male
Other
Family
Single
27
Female
Male
Other
Family
Single
28
Female
Male
Other
Family
Single
29
Female
Male
Other
Family
Single
30
Female
Male
Other
Family
Single
31
Female
Male
Other
Family
Single
32
Female
Male
Other
Family
Single
33
Female
Male
Other
Family
Single
34
Female
Male
Other
Family
Single
35
Female
Male
Other
Family
Single
36
Female
Male
Other
Family
Single
37
Female
Male
Other
Family
Single
38
Female
Male
Other
Family
Single
39
Female
Male
Other
Family
Single
40
Female
Male
Other
Family
Single
41
Female
Male
Other
Family
Single
42
Female
Male
Other
Family
Single
43
Female
Male
Other
Family
Single
44
Female
Male
Other
Family
Single
45
Female
Male
Other
Family
Single
46
Female
Male
Other
Family
Single
47
Female
Male
Other
Family
Single
48
Female
Male
Other
Family
Single
49
Female
Male
Other
Family
Single
50
Female
Male
Other
Family
Single
Submit
Should be Empty: