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Group Health
Group Health Insurance
Free Group Health Quote
Census
United Healthcare Instant Group Quotes
Alternate Funding Health Insurance
Alternate Funding Quote
Other Group Lines
Dental
Vision
Disability
Life
Workers Compensation Form
PEO Services
Individual Plans
Health
Dental
Short Term
University Of Florida (UF) Athletic Camp Insurance
Resources
Search for Physicians and Hospitals
FAQ’s
Welcome to Group Web Enrollment
Glossary of Health Insurance Terms
Privacy & Terms
Blog
Team
Contact Us
Our Staff
Home
Census Form
Number of Employees
*
Enter the number of employees
Employee 1
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 2
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 3
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 4
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 5
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 6
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 7
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 8
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 9
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 10
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 11
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 12
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 13
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 14
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
Child 3 DOB
Child 4 DOB
Child 5 DOB
Employee 15
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 16
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Home Zip
*
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 17
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Home Zip
*
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 18
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Home Zip
*
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 19
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Home Zip
*
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
Employee 20
Name
*
First
Last
DOB
*
Gender
*
---
Male
Female
Home Zip
*
Coverage Type
*
Employee
Employee + Spouse
Employee + Children
Family
Spouse DOB
*
Number of Dependents (Children)
*
Child 1 DOB
*
Child 2 DOB
*
Child 3 DOB
*
Child 4 DOB
*
Child 5 DOB
*
More Than 20 Employees
If you have more than 20 Employees please click submit to download out form
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First Name
*
Last Name
Email
*
Phone
Message
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