Employee Census Form. Group Health Insurance 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the primary individual in the designated field. Ensure accuracy as this information is crucial for identification.
3. Fill in the address, phone number, fax number, and email. This contact information will be used for communication regarding health insurance matters.
4. Detail any medical conditions in the provided space. This section helps assess coverage needs.
5. Indicate your place of employment and current insurance carrier to provide context for your health coverage.
6. Answer whether you smoke and provide your primary date of birth for age-related assessments.
7. List dependents by filling out their names, sex, date of birth, health status, and smoking status in the respective fields.
8. If additional space is needed for dependents, utilize the back of the form as indicated.
9. Finally, check any items you are interested in from the list provided at the bottom of the form to specify your insurance preferences.

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