Employee Census Form		 


(Fields in RED are required)
   
Name of Company:
 
Company Phone: (Include Area Code )
 
Company Fax: (Include Area Code)
 
Name of Contact Person:
 
Contact Person E-mail:
 
Do you currently offer health insurance?
.. No Yes
  
Current Insurance Carrier:
 
Number of covered employees:
 
Renewal Date with current carrier:
YYYY: MM: DD:
 
 

If interested in a quote from WMI Mutual Insurance™ Company, please complete the following census form and fax or email to WMI Mutual Insurance™ Company.
 
Census of Eligible Employees For:    
Name of Employee
Gender
Age
.Type of Coverage
 (Employee,Spouse, Employee & Child, Employee & Children, Family)
Spouse
# of children
  
1.
M F
Y N
 
2.
M F
Y N
 
3.
M F
Y N
 
4.
M F
Y N
 
5.
M F
Y N
 
6.
M F
Y N
 
7.
M F
Y N
 
8.
M F
Y N
 
9.
M F
Y N
 
10.
M F
Y N
 
11.
M F
Y N
 
12.
M F
Y N
 
13.
M F
Y N
 
14.
M F
Y N
 
15.
M F
Y N
 
16.
M F
Y N
 
17.
M F
Y N
 
18.
M F
Y N
 
19.
M F
Y N
 
20.
M F
Y N
 
  If you have more than 20 eligible employees, please submit additional census forms as needed.