PIA Insurance Trust
Hospital Income Census Form
Individual Census Form
This is not an application for insurance.
Please submit a separate census form for each person requesting a proposal.
Name
Gender Male     Female
Agency Name
Address
City State Zip Code
Phone Number
Fax Number
Number of hours worked per week
Date of Birth
Coverage is being requested on: Member/Employee
Member/Employee & Spouse
Member/Employee & Child
Member/Employee & Family

If dependent coverage is being requested: (Only available if Member/Employee has coverage)

Spouse's Name
Date of Birth
Dependent 1 Child's Name
Date of Birth
Dependent 2 Child's Name
Date of Birth
Dependent 3 Child's Name
Date of Birth
Dependent 4 Child's Name
Date of Birth

Benefit Amount: ($50, $100, $150, or $200 daily):

Spouse's benefit amount cannot exceed Member's/Employee's benefit amount. Children's benefit amount cannot exceed 50% of Member's/Employee's benefit amount.
Member/Employee:
Spouse:
Children:
Optional At Home Recovery Lump Sum: Member/Employee
Member/Employee & Spouse
Member/Employee & Family
$1000
$2000