Benefits Connection Exchange

Group Employee Census

Please complete the census for ALL employees. This information is important when the insurance company determines your required participation. ACA Plans require that dependents are listed separately with their birth date and tobacco status. IF YOU HAVE THIS INFORMATION ON AN EXCEL SHEET, YOU CAN FORWARD IT TO US OR USE OUR ONLINE CENSUS FORM.
Employer Information
Company Name: *
Contact Name: *
Contact Email: *
Contact Phone:
Employee Information
  Name Coverage? Date of Birth Date Employed Full/Part Time Tobacco Status
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* = Required Field
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 Local: 302.654.8823

Insurance Products provided through
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 Broker since 1980
302-654-8823
Wilmington, DE 19801
Allen@AllenInsurance.com





 
 
 
 

 


  
 

 
 

 
 

 



      
           
   




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