M & M Insurance Agency

YOUR FUTURE OUR COMMITMENT

877-480-4325

www.MMinsuranceAgency.com

Employee Benefits Census Form

Complete this form to receive accurate benefit quotes

Last Name	First Name	Relationship	Gender	Date of Birth	Coverage	Zip Code	Status	Annual Salary	Action

Coverage Types:

EO = Employee Only | ES = Employee + Spouse

EC = Employee + Children | EF = Employee + Family

Employment Status:

FT = Full-Time | PT = Part-Time | Temp = Temporary

Include disability insurance Include dental insurance Include vision insurance

Additional Notes

Contact Name *

Title

Phone *

Email *

You'll receive a confirmation email after submission

M & M Insurance Agency

YOUR FUTURE OUR COMMITMENT

Phone: 877-480-4325 | Website: www.MMinsuranceAgency.com