EMPLOYEE CENSUS


Please fill out this Employee Census form

 


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Employee 1

Sex: Male Female

Employee 2

Sex: Male Female

Employee 3

Sex: Male Female

Employee 4

Sex: Male Female

Employee 5

Sex: Male Female

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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
2 Wisconsin Circle Suite 700
Chevy Chase, MD 20815

(By Appointment Only)
Phone: (301) 587-4955    Mobile: (301) 442-0010    Toll Free: (800) 369-0110 Fax: (301) 587-8808
www.KossBenefits.com
Check the background of this financial professional on FINRA's BrokerCheck
Check the background of this financial professional on FINRA's BrokerCheck