Weitz Financial Group - : Employee Census Form

Scott Weitz, is an agent licensed to sell insurance through New York Life Insurance Company and may be licensed with various other independent unaffiliated insurance companies in the states of MD, DC, VA, NJ, and SC. No insurance business may be conducted outside the specific states referenced.

Scott Weitz is a Registered Representative of and offers securities products & services through NYLIFE Securities LLC, Member FINRA/SIPC, a Licensed Insurance Agency. In this regard, this communication is strictly intended for individuals residing in the states of MD,DC,VA,and NJ. No offers may be made or accepted from any resident outside the specific states referenced.

Scott Weitz is also seperately registered as an Investment Adviser Representative, under Eagle Strategies LLC, a Registered Investment Adviser, offering advisory services in the states of MD, DC, VA, and NJ. As such, these services are strictly intended for individuals residing in MD, DC, VA,and NJ.

NYLIFE Securities LLC and Eagle Strategies LLC are New York Life companies.

Weitz Financial Group is not owned or operated by NYLIFE Securities LLC or its affiliates.

Scott Weitz is licensed to offer mutual funds and variable products. Market Watch is provided for informational purposes and is not considered an offering of securities.

» Name of Company:
Nature 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:

Employee 6
Name:
Sex:	Male Female
Age:
Family Status:

Employee 7
Name:
Sex:	Male Female
Age:
Family Status:

Employee 8
Name:
Sex:	Male Female
Age:
Family Status:

Employee 9
Name:
Sex:	Male Female
Age:
Family Status:

Employee 10
Name:
Sex:	Male Female
Age:
Family Status:

Employee 11
Name:
Sex:	Male Female
Age:
Family Status:

Employee 12
Name:
Sex:	Male Female
Age:
Family Status:

Employee 13
Name:
Sex:	Male Female
Age:
Family Status:

Employee 14
Name:
Sex:	Male Female
Age:
Family Status:

Employee 15
Name:
Sex:	Male Female
Age:
Family Status: