Koss Benefits Financial & Insurance Services - EMPLOYEE CENSUS : M KossEmployee Censuskossbenefits.com01.13.05


Name of Company:
Name of Business:
Contact Person:
City/State/Zip Code:
Phone Number:
Fax Number:
Current Carrier:
Renewal Date:
Type of Plan:

Current Premium
Single Employee:
Employee/Spouse:
Employee/Child:
Employee/2 or more Children:
Employee/Spouse/Children:

Employee 1
Name:
Sex:	Male Female
Age:
Family Status:

Employee 2
Name:
Sex:	Male Female
Age:
Family Status:

Employee 3
Name:
Sex:	Male Female
Age:
Family Status:

Employee 4
Name:
Sex:	Male Female
Age:
Family Status:

Employee 5
Name:
Sex:	Male Female
Age:
Family Status:


To continue adding employees, Please submit this form, and click on the link provided on the next page to reopen a fresh form. In subsequent forms, enter only your company name. After completing the form, please click on the "Submit" button. PRIVACY NOTICE: All information shall be considered protected health insurance information for the purposes of complying with federal HIPAA privacy rules and requirements. As such, all information will be kept confidential and used only for the purpose of generating insurance illustrations and proposals in response to your request.