May 25, 2018
404-575-1960

Group Employee Census Form

The Employee Census Excel Document is required to prepare the Group Market Analysis.

By completing and submitting the census to HIA, you agree to the Group Advisory Fee of $645.

Please follow these directions carefully to save time for all concerned.

Complete only the yellow columns – skip the white ones.

Group Employee Census Form

  1. Company name and address including the SIC code, if known.
  2. List ALL FULL-TIME W-2 employees, even if they don’t want Medical coverage. Standard definition of full-time is 30 hours/week, but the Employer can change the definition of full-time to 20 hours/week.  The employer will set the full-time requirement when completing the application.
  3. If the employee is unsure if they want coverage for themselves or dependents, please include them and select the drop down in the “Medical” column accordingly. This is not electing coverage, just getting the rates. Only include dependents here if they want to see the rates.
  4. Please refer to the Legend for the “Medical” column dropdown definitions.
  5. If an employee intends to waive medical coverage, indicate that in the “Medical” column by selecting “Waive” from the dropdown. Do not include dependents on the census.
  6. Use dropdowns to select answers where available.
  7. Provide a brief description of your company’s nature of business.
  8. Independent Contractors – 1099’s are not eligible unless an exception is made. If the employer wants to include 1099 employees – please call us regarding an exception.

Please return the census to Toni LePage at Toni@HealthPlanStore.com

Our office will forward the Group Market Analysis to you in approximately 7 days from our receipt of the completed census and then schedule the Benefit Consultation appointment.

Group Health Plan Requirements
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Group Health Plan Advisory Service