Employee Census Form

Name of Business: __________________________________________________________________

Address: ___________________________________________________________________________

Phone: ______________ Fax: ______________ How Long In Business: ________________________

Nature of Business: _________________________________________________________________

Current Insurance Carrier: ___________________________________________________________

SIC Code:  _____________

Name of Employee                     Male/Female    DOB     Coverage*    Residency Zip Code

1. ___________________________________________________________________________________

2. ___________________________________________________________________________________

3. ___________________________________________________________________________________

4. ___________________________________________________________________________________

5. ___________________________________________________________________________________

6. ___________________________________________________________________________________

7. ___________________________________________________________________________________

8. ___________________________________________________________________________________

9. ___________________________________________________________________________________

10. _________________________________________________________________________________

*EO=Employee Only,  ES=Employee Spouse                                   Use back of form if      

 EC=Employee Child(ren),EF=Employee Family                  additional space isneeded

Interested In: {Please check any item(s) you are interested in}

 FBBA

Financial and Business Benefits of America

Hemnath (Hem) De Silva/Broker

Bristow, VA 20136

Phone: 703- 401-6382    

e-mail: FBBA@comcast.net  hdesilva@fbbanet.com  Website: www.fbbanet.com