Helping Clients Complete Their Health Insurance Census Forms

Health Insurance Census

If you’re writing Group Health Insurance or employer-sponsored insurance coverage of any kind, most insurers and plan administrators require a group census to start a quote or begin your group’s enrollment. The census summarizes your group information, so the carrier can provide a better quote.

While questions asked and entry fields can differ by carrier and coverage being applied for, most census forms ask for information about the employer and those to be insured, including eligible dependents.

All or some of the following entries may be included in an employee census:

  • Employer name
  • Employer ZIP Code
  • Nature of business
  • Contact name, phone, and email
  • Effective date requested
  • Current carrier, if any, and number of years with carrier
  • Prior carrier, if any, and number of years with carrier
  • Number of employees to be insured
  • Employee name and SSN
  • Spouse/dependent name and SSN
  • Relationship to employee
  • Employee home ZIP Code
  • Gender of each enrollee
  • Date of birth and/or age
  • Hire date
  • Benefit eligibility date (under employer’s rules)
  • Home address
  • Mailing address (if different than home address)
  • Annual salary
  • Job title
  • Home phone
  • Work phone
  • Email
  • Number of COBRA participants
  • COBRA status for each enrollee (Y/N)
  • Reason for continuation
  • COBRA start date
  • COBRA end date
  • Coverage selected (Medical, Dental, Vision, Other)
  • Specific plan selected
  • Employment status (Full or Part Time, Hourly, Salaried – sometimes asked as number of hours worked per week)
  • Tobacco status (Smoker, Non-smoker)
  • Preferred language (Written/Spoken)
  • Race and ethnicity (not requested by all plans)
  • Primary Care Physician (if selecting HMO)
  • Dental office (if selecting Dental HMO)
  • PCP and/or PPG ID
  • Prior patient (Y/N)
  • Other coverage (Medicare, private)
  • Waiving coverage (Y/N) and, sometimes, reason for waiver

Health Insurance Census Forms and Templates

Many Request For Proposal (RFP) forms also ask for additional information, such as current Medical (HMO and PPO) rates and the employer’s current and/or planned contribution to premiums (for both employees and dependents).

Your client, as the employer, is likely able to easily provide the requested information; however, some fields may require some investigation – such as each employee’s first eligibility date for coverage and language preferences. Be sure to give your client enough time to complete and return the census form without feeling pressured.

Word & Brown offers a variety of carrier and administrator insurance census forms and templates in our online Insurance Forms Library. You can search “census,” and your results will be multiple pages. You can narrow the results by selecting California or Nevada, your market segment, coverage type, carrier, and other fields.

If you have questions, contact your Word & Brown representative or email Broker Resources at W&

We’re adding new forms to our online library all of the time. Be sure to check back regularly to ensure you are using the most recent forms.

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