ASCCA Employee Census

Business Name*
Primary Contact*
Contact Email or Phone Number*
Employer Zip Code*
Input Employee Data (use '+' button to submit multiple records)
Enrollee Type Codes - EE: Employee / SP: Spouse / DM: Domestic Partner / CH: Dependent Child / D-CH: Disabled Dependent Child
Enrollee Type First Name Last Name Birth Date M/F Zip Code
Optional: Upload File(s)
If you have a file such as a spreadsheet with the above information in it, you can upload it here. Allowed file types: jpg, gif, png, pdf, xls, csv, doc, jpeg, tif, tiff, xml, html, psd, eps, ai, svg. If your file type isn't allowed, please let us know via the contact form and we'll add it for you asap. Thank you!
Drop files here or

Accepted file types: jpg, gif, png, pdf, xls, csv, doc, jpeg, tif, tiff, xml, html, psd, eps, ai, svg.

Employee Census

Enrollee Type	First Name	Last Name	Birth Date	M/F	Zip Code