Progressive Benefits: Census Form

Please complete every field for each employee listed. If you would like to submit information for more than 20 employees, please use our printable/faxable form.

	Click here for printable/faxable form - (requires Adobe Acrobat Reader)
	To adjust this window (screen), place your mouse on the blue title bar and move the window accordingly.
	Click to close this window.

Group Name:

Telephone Number:

Contact Person:

Location:

City:

County:

State:

Zip:

Efective Date of Coverage:

Type of Plan:

HMO PPO POS

#	Name	Sex	Age/DOB	Spouse/DOB *If available	Family States *Key Below	Class*	Occupation*	Salary*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

* For Long Term and Short Term Disability only.

FAMILY STATUS KEY:
Single = 1
Employee/Spouse = 2
Employee/Child(ren) = 3 (then # of children)
Family = 4

Progressive Benefits - 31300 Solon Road #8 - Solon , Ohio 44139
Phone(216)464-6200 - Fax(216)464-5665