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[null,"Employee Census"]
[null,null,"EMPLOYER INFORMATION:\n\nIn the space provided below please provide the name and address of your company, the name, phone number and email of the contact, a brief description of your business, your SIC (if known) and the date that you wish your benefits to begin.  In addition please indicate the benefits for which you would like us to obtain quotes."]
[null,"Employer Name: ",null,null,null,"Physical Address:    "]
[null,"Contact Name: ",null,null,null,"Contact Phone: ",null,"Contact Email:  "]
[null,"Business Description:    ",null,null,null,"Are all employees, including executives, covered by Workers' Compensation?    £Yes £No"]
[null,"SIC (If Known):  ",null,null,null,"Desired Effective Date:    "]
[null,"Requested Benefits:"]
[null,"EMPLOYER INFORMATION:","# of Full-Time Employees:  ",null," # of Part-Time Employees:    ",null,"# of Employees Waiving Coverage:"]
[null,"Please provide the requested information in the space provided below. (An eligible employee is generally one who is working at least 30 hours in a normal week.) Be sure to include the date of birth for both the employee, spouse and child(ren), if applicable.  IMPORTANT: please indicate if the employee intends to enroll or waive coverage under your health plan. You may use an employee ID number, last name, or any other identifying information in the first column.  Please email your completed census to wendee@pnwisol.com.  If you have any questions, please contact us at 425-314-0988. Thank you!"]
[null,"Relationship to Employee\n(Employee; Spouse; Child)","Last Name","First Name","Gender \n(M/F)","Date of Birth (MM/DD/YYYY)","Residential          ZIP Code","E = Enroll\nW = Waive","Job Title\n(Required For Disability and/or Life  Coverage Only)","Annual Salary\n(Required For Disability and for Life Coverage if Life Coverage is Based on Salary)"]
["O"]