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renee@commercialbenefits.com

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Commercial Benefit Services, Inc.

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Census Request Materials

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Census Request
Census Request “Sample”
Census Request

On each employee and each dependent, we will need the following. 

    • Date of Birth
    • Gender (male or female)
    • Zip Code of Residence and Work (only need work zip for employees, not dependents)
    • Whether they are a tobacco user or not

If they are part-time, we do not need dependent information.

Please remember that we need this information for all insureds, including dependents. The census also needs to
include part-time employees, even though they are not eligible for coverage, as well as employees who have declined due to other coverage.

In addition to the census, we also need your current carrier (if any), and a copy of your current rates and benefits.

Census Request “Sample”

New census template-sample

Record #Employee Record #*RelationshipLast NameFirst Name*DOB or AgeGenderHome Zip*Work ZipMedicalDentalVisionLife*Life VolumeDisabilityAnnual Salary# ChildrenMedicare EnrolleeCobra or State ContinuationSmokerRetiredDisabled
1EmployeeSmithJoe35F8002180306ESESESEEWaive45000NNYN
1SpouseSmithKatie35M80021ESESESEENNYN
2EmployeeShmidtAlan30F8052280306EFEFEFEEWaive500001NNNN
2SpouseShmidtSamantha30M80522EFEFEFEENNNN
2ChildShmidtTina12M80522EFEFEFEENNNN
3EmployeeBautistaPatrick33F8099580306ECECECEEWaive485003NNYN
3ChildBautistaAngelo10M80995ECECECEENNNN
3ChildBautistaSteve6M80995ECECECEENNNNY
3ChildBautistaNickie3F80995ECECECEENNNN
4EmployeeGhalyRichard33M8086380306ECECECEEWaive600001NNNN
4ChildGhalyWilliam5M80863ECECECEENNNN

Get Ready Set GO!!!

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713-956-5522

renee@commercialbenefits.com

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