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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 #	*Relationship	Last Name	First Name	*DOB or Age	Gender	Home Zip	*Work Zip	Medical	Dental	Vision	Life	Disability	Annual Salary	# Children	Medicare Enrollee	Cobra or State Continuation	Smoker	Retired	Disabled
1		Employee	Smith	Joe	35	F	80021	80306	ES	ES	ES	EE	Waive	45000		N	N	Y	N
	1	Spouse	Smith	Katie	35	M	80021		ES	ES	ES	EE				N	N	Y	N
2		Employee	Shmidt	Alan	30	F	80522	80306	EF	EF	EF	EE	Waive	50000	1	N	N	N	N
	2	Spouse	Shmidt	Samantha	30	M	80522		EF	EF	EF	EE				N	N	N	N
	2	Child	Shmidt	Tina	12	M	80522		EF	EF	EF	EE				N	N	N	N
3		Employee	Bautista	Patrick	33	F	80995	80306	EC	EC	EC	EE	Waive	48500	3	N	N	Y	N
	3	Child	Bautista	Angelo	10	M	80995		EC	EC	EC	EE				N	N	N	N
	3	Child	Bautista	Steve	6	M	80995		EC	EC	EC	EE				N	N	N	N	Y
	3	Child	Bautista	Nickie	3	F	80995		EC	EC	EC	EE				N	N	N	N
4		Employee	Ghaly	Richard	33	M	80863	80306	EC	EC	EC	EE	Waive	60000	1	N	N	N	N
	4	Child	Ghaly	William	5	M	80863		EC	EC	EC	EE				N	N	N	N

Get Ready Set GO!!!

Let Commercial Benefit Services, LLC. give you a quote this year.