Employee Benefit Census

Agent         Pierre Granger CLU      Tel: 954-328-6750           Fax: (305) 556-3680

Business name, address and telephone                                     Contact

Coverage Rypes: E employee only, S with spouse, C with children, F for Family

Employee's                   Employee                  Employee             Employee                     Employee                  Coverage

Name(Optional)               Sex                     Age/Date of Birth   Residence/Zipcode    Residence/County                Type