Instructions for completing this form

  1. Group Name is the name of your dental practice.
  2. Include yourself on the census form as an employee of the practice.
  3. Provide all requested information on each employee who is electing to enroll in coverage.
  4. 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.