Benefits Connection Exchange

Aetna AFFINITY Employee Census

PLEASE COMPLETE THE CENSUS FOR ALL FULL TIME EMPLOYEES. IF DEPENDENTS ARE TO BE COVERED, BE SURE TO INCLUDE THEIR INFORMATION. IF YOU HAVE THIS INFORMATION ON AN EXCEL SHEET THAT WILL INCLUDE ALL THE REQUIRED INFORMATION YOU CAN FORWARD IT TO US IN PLACE OF THIS FORM.
Employer Information
Company Name: *
Contact Name: *
Contact Email: *
Contact Phone:
Current Insurance Company
Renewal Date
Employee Information
Please complete the census for ALL FULL TIME employees. IF DEPENDENTS ARE TO BE COVERED, BE SURE TO INCLUDE THEIR INFORMATION. IF YOU HAVE THIS INFORMATION ON AN EXCEL SHEET THAT WILL INCLUDE ALL THE REQUIRED INFORMATION YOU CAN FORWARD IT TO US IN PLACE OF THIS FORM.
  Name Relationship Date of Birth Full/Part Time Covered Now? EMAIL (Employee's)
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* = Required Field
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