Employee Census Form (Health, Life & Disability Plans)
Please complete the form below....
Company Name:
Contact Person:
Mailing Address:
City, State Zipcode:
Phone Number:       Fax: 
E-Mail Address:
What does Your Business DO?
County:
Employees
1 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
2 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
3 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
4 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
5 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
6 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
7 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
8 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
9 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
10 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
11 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
12 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance:
 Weekly Disability Benefit: 
13 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
14 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
15 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
16 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
17 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
18 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
19 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 
20 Sex
M / F		 Age or Birth Date
Employee Home Zipcode
Medical Benefits:
 Employee Life Insurance: 
 Weekly Disability Benefit: 

Please provide quotes on.......
Medical
Health Savings Plan
Short Term Disability
Long Term Disability
Dental Plans
Vision Plans
Profit Sharing/Pension Plans

Home Page
E-Mail

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway     Murrysville, PA.   15668
(724) 327-8474      fax: (724) 327-7911
Toll Free: 1-800-977-2999     Fax: 1-888-800-0034