Worksheet for Groups of 2 to 50 employees.

If you do not wish to use this online form, please send your group's census and information to:

• Email: quotes@mclaren.org
• Fax: (810) 733-9596
• Mail:
  McLaren Health Plan
  G-3245 Beecher Rd
  Suite 200
  Flint, MI 48532

Before beginning, please gather the following information:

• Employee ZIP Code
• Employee Date of Birth
• Spouse Date of Birth
• Date(s) of Birth for Dependents (ages 0-26)
• The requested start date for your McLaren Health Plan coverage

A McLaren Health Plan representative will contact with you within a few days of receiving the completed information.

Your proposal will include our standard health insurance plan designs with Dental and Vision options.

Please complete the following information.

Note: Fields marked with an * indicates required field

Contact Person: * Contact Person:

Email Address: * Email Address:

Company Name: * Company Name:

Address: * Address:

City: * City:

Zip Code: * ZIP Code:

Telephone: * Telephone:

Effective Date of Plan: * Effective Date of Plan:

Agent: Agent:

Agents Phone: Agent's Phone:

Comments: Comments:

EMPLOYEE CENSUS

Employees

Count	ZIP Code (Employee's Residence)	Employee Date of Birth (MM/DD/YYYY)	Spouse/Partner1 Date of Birth (MM/DD/YYYY)	Date(s) of Birth of Covered Children, ages 0-26 (MM/DD/YYYY, comma-separated)
Count 1: *	Zip Code 1: * *	Employee Age 1: * *	Spouse Age 1:	Number of Children 1:
Count 2: *	Zip Code 2: * *	Employee Age 2: * *	Spouse Age 2:	Number of Children 2:
Count 3:	Zip Code 3:	Employee Age 3:	Spouse Age 3:	Number of Children 3:
Count 4:	Zip Code 4:	Employee Age 4:	Spouse Age 4:	Number of Children 4:
Count 5:	Zip Code 5:	Employee Age 5:	Spouse Age 5:	Number of Children 5:
Count 6:	Zip Code 6:	Employee Age 6:	Spouse Age 6:	Number of Children 6:
Count 7:	Zip Code 7:	Employee Age 7:	Spouse Age 7:	Number of Children 7:
Count 8:	Zip Code 8:	Employee Age 8:	Spouse Age 8:	Number of Children 8:
Count 9	Zip Code 9:	Employee Age 9:	Spouse Age 9:	Number of Children 9:
Count 10:	Zip Code 10:	Employee Age 10:	Spouse Age 10:	Number of Children 10:
Count 11:	Zip Code 11:	Employee Age 11:	Spouse Age 11:	Number of Children 11:
Count 12:	Zip Code 12:	Employee Age 12:	Spouse Age 12:	Number of Children 12:
Count 13:	Zip Code 13:	Employee Age 13:	Spouse Age 13:	Number of Children 13:
Count 14:	Zip Code 14:	Employee Age 14:	Spouse Age 14:	Number of Children 14:
Count 15:	Zip Code 15:	Employee Age 15:	Spouse Age 15:	Number of Children 15:
Count 16:	Zip Code 16:	Employee Age 16:	Spouse Age 16:	Number of Children 16:
Count 17:	Zip Code 17:	Employee Age 17:	Spouse Age 17:	Number of Children 17:
Count 18:	Zip Code 18:	Employee Age 18:	Spouse Age 18:	Number of Children 18:
Count 19:	Zip Code 19:	Employee Age 19:	Spouse Age 19:	Number of Children 19:
Count 20:	Zip Code 20:	Employee Age 20:	Spouse Age 20:	Number of Children 20:
Count 21:	Zip Code 21:	Employee Age 21:	Spouse Age 21:	Number of Children 21:
Count 22:	Zip Code 22:	Employee Age 22:	Spouse Age 22:	Number of Children 22:
Count 23:	Zip Code 23:	Employee Age 23:	Spouse Age 23:	Number of Children 23:
Count 24:	Zip Code 24:	Employee Age 24:	Spouse Age 24:	Number of Children 24:
Count 25:	Zip Code 25:	Employee Age 25:	Spouse Age 25:	Number of Children 25:
Count 26:	Zip Code 26	Employee Age 26:	Spouse Age 26:	Number of Children 26:
Count 27:	Zip Code 27:	Employee Age 27:	Spouse Age 27:	Number of Children 27:
Count 28:	Zip Code 28:	Employee Age 28:	Spouse Age 28:	Number of Children 28:
Count 29:	Zip Code 29:	Employee Age 29:	Spouse Age 29:	Number of Children 29:
Count 30:	Zip Code 30:	Employee Age 30:	Spouse Age 30:	Number of Children 30:
Count 31:	Zip Code 31:	Employee Age 31:	Spouse Age 31:	Number of Children 31:
Count 32:	Zip Code 32:	Employee Age 32:	Spouse Age 32:	Number of Children 32:
Count 33:	Zip Code 33:	Employee Age 33:	Spouse Age 33:	Number of Children 33:
Count 34:	Zip Code 34:	Employee Age 34:	Spouse Age 34:	Number of Children 34:
Count 35:	Zip Code 35:	Employee Age 35:	Spouse Age 35:	Number of Children 35:
Count 36:	Zip Code 36:	Employee Age 36:	Spouse Age 36:	Number of Children 36:
Count 37:	Zip Code 37:	Employee Age 37:	Spouse Age 37:	Number of Children 37:
Count 38:	Zip Code 38:	Employee Age 38:	Spouse Age 38:	Number of Children 38:
Count 39:	Zip Code 39:	Employee Age 39:	Spouse Age 39:	Number of Children 39:
Count 40:	Zip Code 40:	Employee Age 40:	Spouse Age 40:	Number of Children 40:
Count 41:	Zip Code 41:	Employee Age 41:	Spouse Age 41:	Number of Children 41:
Count 42:	Zip Code 42:	Employee Age 42:	Spouse Age 42:	Number of Children 42:
Count 43:	Zip Code 43:	Employee Age 43:	Spouse Age 43:	Number of Children 43:
Count 44:	Zip Code 44:	Employee Age 44:	Spouse Age 44:	Number of Children 44:
Count 45:	Zip Code 45:	Employee Age 45:	Spouse Age 45:	Number of Children 45:
Count 46:	Zip Code 46:	Employee Age 46:	Spouse Age 46:	Number of Children 46:
Count 47:	Zip Code 47:	Employee Age 47:	Spouse Age 47:	Number of Children 47:
Count 48:	Zip Code 48:	Employee Age 48:	Spouse Age 48:	Number of Children 48:
Count 49:	Zip Code 49:	Employee Age 49:	Spouse Age 49:	Number of Children 49:
Count 50:	Zip Code 50:	Employee Age 50:	Spouse Age 50:	Number of Children 50:
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