EMPLOYEE CENSUS

Please fill out this Employee Census form

» Required Fields

»
»
»
»
»
»

Current Premium


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

Employee 6

Sex: Male Female

Employee 7

Sex: Male Female

Employee 8

Sex: Male Female

Employee 9

Sex: Male Female

Employee 10

Sex: Male Female

Employee 11

Sex: Male Female

Employee 12

Sex: Male Female

Employee 13

Sex: Male Female

Employee 14

Sex: Male Female

Employee 15

Sex: Male Female
Richard A. Fancher d/b/a Fancher Financial Services
7500 College Blvd Suite 800 P.O.Box 25414
Shawnee Mission, KS 66225-5414
Phone: USA 913-661-7241 or 913-661-7247 Fax: 913-661-7298
www.fancherfinancialservices.com