Business Digital Census Tool | American Insurance Guide
American
Insurance
Guide
Digital Census Tool
Primary Contact
Name
Phone Number
Email Address
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
Number of Employees
Employee Census
Select Number of Employees...
Employee Name
Home Zip
DOB
Select
Male
Female
Gender
Self
Spouse
Child
Relationship
4'10"
4'11"
5'
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
Height
80-150lbs
151-200lbs
201-250lbs
251-320lbs
Weight
None
1
2
3
4
5
6+
Medications
Yes
No
Currently Insured
1
2
3
4
5
6
7
8
Dependents
Dependents
Dependent 1
Select
Spouse
Child
Relationship
Name
DOB
Select
Male
Female
Gender
4'10"
4'11"
5'
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
Height
80-150lbs
151-200lbs
201-250lbs
251-320lbs
Weight
Dependent 2
Select
Spouse
Child
Relationship
Name
DOB
Select
Male
Female
Gender
4'10"
4'11"
5'
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
Height
80-150lbs
151-200lbs
201-250lbs
251-320lbs
Weight
Dependent 3
Select
Spouse
Child
Relationship
Name
DOB
Select
Male
Female
Gender
4'10"
4'11"
5'
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
Height
80-150lbs
151-200lbs
201-250lbs
251-320lbs
Weight
Employee Name
Home Zip
DOB
Select
Male
Female
Gender
Self
Spouse
Child
Relationship
4'10"
4'11"
5'
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
Height
80-150lbs
151-200lbs
201-250lbs
251-320lbs
Weight
None
1
2
3
4
5
6+
Medications
Yes
No
Currently Insured
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