Benefits Employee Information – Clozzits

As part of reviewing our employee benefits, we are gathering basic census information to obtain updated plan quotes. Please provide the requested details for yourself and any dependents (name, date of birth, gender, relationship, and home ZIP code). This information will be used only for benefits quoting purposes and will be handled in accordance with applicable privacy and HIPAA guidelines.

Name *

First

Last

Email *

Date of Birth *

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Gender *

• Female
• Male

Home Zip Code *

Dependents Information

Include ALL information for each dependent that have in your household.

Spouse Information

Spouse - Name

First

Last

Spouse - Date of Birth

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Spouse - Gender

• Female
• Male

Spouse - Home Zip Code

Child 1 Information

Child 1 - Name

First

Last

Child 1 - Date of Birth

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Child 1 - Gender

• Female
• Male

Child 1 - Home Zip Code

Child 2 Information

Child 2 - Name

First

Last

Child 2 - Date of Birth

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Child 2 - Gender

• Female
• Male

Child 2 - Home Zip Code

Child 3 Information

Child 3 - Name

First

Last

Child 3 - Date of Birth

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Child 3 - Gender

• Female
• Male

Child 3 - Home Zip Code

Child 4 Information

Child 4 - Name

First

Last

Child 4 - Date of Birth

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Child 4 - Gender

• Female
• Male

Child 4 - Home Zip Code

ADDITIONAL CHILDREN

If you have more than 4 children, please include their information here (First name, Last name, Date of Birth, Gender, and Home Zip code).

Submit