Group Census Form
	Phone 979-793-7990 Fax 979-793-7993
	george@winterhawkinsurance.com						CONFIDENTIAL
		Firm Name:
		Address:
		City:			State:		Zip:
		Nature of Business:					SIC code:
							(if available)
	Employee Information					Complete this section only if requesting a quote for Group Disability and/or 401(k)/Profit Sharing
	Name	Gender	Date of Birth	Spouse's Date of Birth	Number of Children	Occupation	Date of Hire	Monthly Salary	Work Location Zip Code*
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	*Complete this column ONLY if the Employer has multiple worksites/locations.