Instructions for completing this form
- Group Name is the name of your dental practice.
- Include yourself on the census form as an employee of the practice.
- Provide all requested information on each employee who is electing to enroll in coverage.
- If enrolling spouses/children, complete requested information for those individuals.
* If you have 50 or more full-time equivalent employees, you must offer “affordable” coverage to all employees who work 30 hours or more per week. This means employees’ premiums for self-only coverage cannot exceed 9.5% of their household income. This may influence your decision on how much to contribute on behalf of your employees.