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Employee Census Form Questions?

Call Toll-Free (888) 474-6627

Click here to download a blank Employee Census Form. Fill it out and return to HPO via
or fax to (888) 474-6627.

IMPORTANT - Before completing this form, please read the following information. The Employee Census Form asks for the following information:

  • Employee Name (This entry may be blank, but the field cannot be omitted)
  • Date of Hire (mm-dd-yyyy)
  • Employee Home Zip Code
  • Date of Birth (mm-dd-yyyy)
  • Gender (Use M for Male, F for Female)
  • Job Title (Use if LTD quote is desired)
  • Annual Earnings (Use if LTD or Life quote is desired) (This must be NUMERIC)
  • Family Status (EE=Single Employee, ES=Emp+Spouse, EC=Emp+Child(ren), EF=Family)
  • Plan Participation (HMO, PPO or POS)

Submission of a census does not constitute existence of an employee benefits program.  Additional information may be required. A representative will contact you to acknowledge receipt of your census and review the proposal process.