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Employee Census: Health
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Employer Name:
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*
Address:
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City, State, Zipcode:
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Phone:
*
Email:
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Note
: You must include all eligible COBRA employees in the census
*
Name orIinitials
*
Gender
*
Date of Birth mm/dd/yyy
*
Spouse Coverage
Number of children
1.
Select
Male
Female
Select
Yes
No
Select
1
2
3+
2.
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Male
Female
Select
Yes
No
3.
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Male
Female
Select
Yes
No
4
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Male
Female
Select
Yes
No
5
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Male
Female
Select
Yes
No
6
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Male
Female
Select
Yes
No
7
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Male
Female
Select
Yes
No
8
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Male
Female
Select
Yes
No
9
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Male
Female
Select
Yes
No
10
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Male
Female
Select
Yes
No
11
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Male
Female
Select
Yes
No
12
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Male
Female
Select
Yes
No
13
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Male
Female
Select
Yes
No
14
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Male
Female
Select
Yes
No
15
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Male
Female
Select
Yes
No
16
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Male
Female
Select
Yes
No
17
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Male
Female
Select
Yes
No
18
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Male
Female
Select
Yes
No
19
Select
Male
Female
Select
Yes
No
20
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Male
Female
Select
Yes
No
21
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Male
Female
Select
Yes
No
22
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Male
Female
Select
Yes
No
23
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Male
Female
Select
Yes
No
24
Select
Male
Female
Select
Yes
No
35
Select
Male
Female
Select
Yes
No
*
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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