Our Online Census Form helps you create a census for your group quickly and easily. If you have any questions, please Contact Us  and we'll be happy to help.

Please fill out the following form to submit your group census data.

* Denotes Required Fields.

* Company Name					* Your Name
* Telephone Number					* Email Address
* Fax Number					* Best Time To Call	-- Please Select Time Period -- Anytime Early Morning 8:00 AM TO 10:00 AM Late Morning 10:00 AM to 12:00 AM Early Afternoon 1:00 PM to 3:00 PM Late Afternoon 3:00 PM to 5:00 PM Evening After 5:00 PM
* Address					* City           * Number Of Employees
* State					* Zip                                 * Number On Group Plan
					* List SIC Code or Briefly Describe Your Business Operation
Comments

* Do you already have a group census that you would prefer to fax or email us? Yes No

If yes please fax to:  936-448-1012 or email  to : edhemphill@hemphillinsuranceagency.com ; please be sure to click the submit button at bottom of this form before you exit this web page (Please skip completion of online census form shown below ) .

* Does your firm currently employ 51 or more employees ? Yes No

If " Yes " our  insurance counselor will contract you to discuss your current carriers benefit plan , claims experience   ( loss history ) , and type employee benefit plans you would like to consider . Click submit button at bottom of this form ( Please skip completion of online census form shown below ) .

Employee Name		Age	Sex	Home Zip	Coverage Type	#/Children            ( provide # only if children   coverage requested)
1.			M   F		Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
2.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
3.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
4.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
5.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
6.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
7.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
8.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
9.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
10.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
11.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
12.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
13.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
14.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
15.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
16.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
17.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
18.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
19.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
20.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
21.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
22.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
23.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
24.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
25.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
26.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
27.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
28.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
29.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
30.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
31.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
32.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
33.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
34.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
35.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
36.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
37.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
38.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
39.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
40.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
41.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
42.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
43.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
44.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
45.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
46.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
47.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
48.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
49.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
50.			M   F		Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

Clicking Submit will send this census to Hemphill Insurance Agency for processing. A Certified Insurance Counselor will contact you within 24 hours to discuss  the plan benefits (deductible/office visit copay/prescription drug copays)  your group would like to consider.