Mailing Response
(Fields marked * are required fields)
Employee Census
Employee Name / Smoker or Non | Male or Female | Date of Birth(mm-dd-yyyy) |
Type of Medical Coverage (see codes below) | Spouse DOB(mm-dd-yyyy) |
Dates of Birth of Children(mm-dd-yyyy) | Residential Zip Code | Household Yearly Salary | ||
Coverage Codes for Medical:
EE = Employee Only
EC = Employee + Child(ren)
ES = Employee + Spouse
EF= Employee + Spouse and Child(ren)
W - Waived, not taking coverage
EE = Employee Only
EC = Employee + Child(ren)
ES = Employee + Spouse
EF= Employee + Spouse and Child(ren)
W - Waived, not taking coverage