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.
  • If dependent coverage is being requested:

    (Only available if Member/Employee has coverage)
  • 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.