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Company and Contact Information
Your Company Name
Company Zipcode
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Contact Name
Phone Number
Email Address

Company Contribution Strategy
Select your Company Contribution Strategy, Don't worry we can adjust this later at any time.
Generous: (Employer pays 80% of Highest Silver Plan for Employee and Dependents). Good with Family members: (Employer pays 70% of Lowest Silver Plan for Employee Only and 40% for Dependents). Good, Employee Only: (Employer pays 70% of Lowest Silver Plan for Employee Only). Medium: (Employer pays 50% of Lowest Bronze Plan for Employee Only's). Low: (Employer pays 10% of Lowest Bronze Plan for Employee Only, May allow some older and lower paid employees to go to the Exchange for Tax Credits). Lump Amount, Family: (Employer pays up to a single amount for each Family). $/m Lump Amount, Employee Only: (Employer pays up to a single amount for each Employee Only). $/m

Census Information
Do you already have a census? We can upload it for you! Just use one of the email address above to send it to us.YesNo
	Employee Name	Home Zip Code 5 digit	Estimated Family Income $/yr (Optional)	Employee Date of Birth (mm/dd/yyyy)	Spouse Date of Birth (mm/dd/yyyy)	Child 1 Date of Birth (mm/dd/yyyy)	Child 2 Date of Birth (mm/dd/yyyy)	Child 3 Date of Birth (mm/dd/yyyy)	Child 4 Date of Birth (mm/dd/yyyy)	Child 5 Date of Birth (mm/dd/yyyy)	Child 6 Date of Birth (mm/dd/yyyy)
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Company and Contact Information