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Group Health Insurance Census Form
At Amante and Associates we develop personalized benefit solutions for you and your employees. Please fill out the online form and a member of our team will call you within one business day or contact us at your convenience at (951)676-8800.

Company Name:
*Contact Person:
Phone #:
Fax #:
*Email Address:
Group Plan(s) Desired:	Group Health  Group Dental  Group Life  Group Disability  Section 125 (Cafeteria Plans)  COBRA Administration  Group Retiree Health Plans  HSA Plans  H.R. Services
*Comments:
If you have your employee file in Word or Excel format, you may select and upload it by clicking the following button. If not, complete the following census form or we will contact you to obtain the information.
Employee Name Sex Date of Birth Married Children Zip Add Gender F M n/a Y N 0 1 2 3 4 5 6 7 8 9 +