EMPLOYEE CENSUS

Please fill out this Employee Census form


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.

Koss Benefits Financial & Insurance Services

1601 BRIGHTON DAM RD

BROOKEVILLE, MD 20833

Phone: Mobile: (301) 442-0010 Toll Free: (800) 369-0110

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Fax: (301) 587-8808

www.KossBenefits.com

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mkoss@kossbenefits.com

Securities offered through LPL Financial, member FINRA & SIPC. Investment advice offered through Global Retirement Partners LLC, a registered investment advisor. Anderson Financial, Koss Benefits Financial & Insurance Services and Global Retirement Partners, LLC are separate entities from and not affiliated with LPL Financial.

The financial professionals associated with LPL Financial may discuss and/or transact business only with residents of the states in which they are properly registered or licensed. No offers may be made or accepted from any resident from any other state.

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