Employee Census | Fairbanks Family Insurance Co.

What company are you employed with / contracted with? *

Full name *

Date of birth *

Phone *

Email *

Zip code * (where you live, not work)

Height (ft) *

Height (in) *

Weight (lbs) *

Do you use tobacco or nicotine? *

Yes No

What medications are you currently taking? * List them out, or write "none" if you're not taking any.

What health conditions do you have? * Diagnosed conditions, ongoing or past. Write "none" if none apply.

+ Add spouse (optional)

Full name

Date of birth

Height (ft)

Height (in)

Weight (lbs)

Does your spouse use tobacco or nicotine?

Yes No

What medications is your spouse currently taking? List them out, or write "none" if they're not taking any.

What health conditions does your spouse have? Diagnosed conditions, ongoing or past. Write "none" if none apply.

+ Add children (optional)

Just age and sex for each child — leave any unused rows blank.

Child 1

Child 2

Child 3

Child 4

Child 5

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