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Employee Census: Dental
Fields marked with (
*
) are required
*
Employer Name:
*
Address:
*
City, State, Zipcode:
*
Phone:
*
Nature of Business:
Note
: You must include all eligible COBRA employees in the census
*
Employee Name
*
Gender
*
Date of Birth
*
Coverage Status
*
HMO or PPO
*
Employee Status
**
State
Zipcode
Location
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*
EE - Employee Only
**
A - Actively at work
*
E&SP - Employee & Spouse
**
C - Cobra/State Continuation
*
E&CH - Employee & Child(ren)
**
P/T Part Time
*
FAM - Family
**
W - Waive Coverage
**
L - Life Only
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