Employee Benefits Census Form
Please complete all sections to help us accurately build the Employee Benefits Census Form. All fields are required for census intake. Do not include sensitive personal or financial information.
Employee Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Employee Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee ID or Internal Reference Number (non-sensitive format)
*
Department / Team
*
Job Title
*
Employment Status
*
Please Select
Full-Time
Part-Time
Contractor
Temporary
Intern
Other
Work Location
*
Dependent Coverage Needed?
*
Yes
No
Benefit Enrollment Notes or Special Instructions
Submit
Should be Empty: