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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.
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