PIA Insurance Trust
Term Life Census Form
Census Form
This is not an application for insurance.
PLEASE NOTE: This online form will accommodate up to 15 employees. If you have more than 15 employees, please download the census form as a PDF, complete, and mail/fax to us. Thank you.
Agency Name
Sponsoring Member's Name
Effective Date of Membership
Address
City State Zip Code
Phone Number      Fax Number
E-Mail Address

MEMBER / EMPLOYEE 1

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 2

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 3

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 4

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 5

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 6

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 7

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 8

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 9

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 10

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 11

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 12

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 13

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 14

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

MEMBER / EMPLOYEE 15

Name        
Date of Birth     Date of Hire     Hours/Week  
Class  (If you are not sure what class to choose, See Class Details for help.)

Amount of Coverage       

CERTIFICATION

I certify that this is a complete list of eligible employees and I agree to pay 100% of the premium for these employees.   
Agency Owner/Partner/Officer/Agency Manager  
Date