Employee Census Form (Health, Life & Disability Plans)
Please complete the form below....
Company Name:
Contact Person:
Mailing Address:
City, State Zipcode:
Phone Number:       Fax: 
E-Mail Address:
What does Your Business DO?
County:
Employees
1 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
2 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
3 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
4 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
5 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
6 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
7 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
8 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
9 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
10 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
11 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
 Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
12 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
13 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
14 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
15 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
16 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
17 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
18 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
19 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$
20 Sex
M / F 		Age or Birth Date
Employee Home Zipcode
Medical Benefits:
Annual Payroll:$
Employee Life Insurance:$
Weekly Disability Benefit:$

Please provide quotes on.......
Medical Coverage Health Savings Plan Short Term Disability
Long Term Disability Dental Plans Vision Plans
Profit Sharing/Pension Plans

Home Page
E-Mail

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway     Murrysville, PA.   15668
(724) 327-8474      fax: (724) 327-7911
Toll Free: 1-800-977-2999