February 23, 2012
Russell & Schrader Insurance Agency, Inc.

Employee Census

Employer Information
Company Name: *
Contact Name: *
Contact Email: *
Contact Phone:
Employee Information
  Name Date of Birth Sex Annual Income
(for disability only)		 Occupation Date Employed County
(or Zip)		 Covered
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
* = Required Field
Send