Ron Powell & Associates LLC Group Census Form
GROUP NAME: GROUP ADDRESS: EFFECTIVE DATE: TYPES OF COVERAGE INDUSTRY SIC: EE = EMPLOYEE ONLY ES=EMPLOYEE & SPOUSE EC=EMPLOYEE & CHILDREN F= FAMILY W=WAIVE COVERAGERequesting agency: Ron Powell & Associates 1300 McGee Drive, Suite 105 Norman, OK 73072 (405) 321-0101 fax (405) 321-0105 ronpowellinsurance@outlook.com NAME/INITIALS GENDER EMPLOYEE DOB/AGE SPOUSE DOB/AGE CHILD 1 AGE/DOB CHILD 2 AGE/DOB CHILD 3 AGE/DOB CHILD 4 AGE/DOB COVERAGE
1.
2.
3.
4.
5
6.
7.
8.
9.
10.
11.
12
13
14
15
16.
17.
18.
19.
20.