The information provided by this form will generate a customized census form. Some carriers base rates on the residence zip code of each employee. Rates for these carriers will be based on the employer zip code if residence zip codes are not input, which could cause inaccurate rates.
Information about the company
Employer Name
Employer Zip
.90
.91
.92
.93
.94
.95
.96
.97
.98
.99
1.0
1.01
1.02
1.03
1.04
1.05
1.06
1.07
1.08
1.09
1.10
RAF
# of emps to cover
Employee census data that is available
Employee names (will appear on quote)
Employee dates of birth
Employee ages
Residence zip codes
