Colorado Insurance Benefits Group Census Form
Customer Details:
Name of Business
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nature of Business
Business Contact Name
First Name
Last Name
Business Contact Email
example@example.com
Employee List
Rows
Date of Birth or Age
Sex
Home Zip Code
Dependents to Consider? (Y or N)
Employee 1
Employee 2
Employee 3
Employee 4
Employee 5
Employee 6
Employee 7
Employee 8
Employee 9
Employee 10
Employee 11
Employee 12
Employee 13
Employee 14
Employee 15
Dependents of:
Rows
Date of Birth or Age
Sex(M or F)
Relationship to Employee
Currently Insured (Y or N)
Employee 1
Employee 2
Employee 3
Employee 4
Employee 5
Employee 6
Employee 7
Employee 8
Employee 9
Employee 10
Employee 11
Employee 12
Employee 13
Employee 14
Employee 15
Addition Comments:
Submit
Should be Empty: