Thank you for your interest in a group insurance proposal from NHADA. You can refer to these instructions for completing the group insurance census.
You must include all employees even if they are not electing insurance.
For each person, including family members of employees who would like coverage, please fill in the Names, Date of Birth (mm/dd/yyyy), Zip Code, and Gender fields.
Coverage Type - Required field for subscriber (employee) only:
- EE = Employee Only
- ES = Employee + Spouse
- EC = Employee + 1 Child
- EC+ = Employee + more than one child
- FAM = Family (employee + spouse + 1+ child)
- W = Waive Coverage -Employee declining coverage due to coverage under:
- Another group plan as spouse/dependent
- Mass Health, Medicare or Veteran plan
- Another group plan from second employer
- Insurance through a state or federal exchange - only if premium is subsidized
- WO = Waive Other
- Employee declining coverage due to coverage under:
- Another group plan from this employer
- A non-group , individual or private health care plan
- An Unsubsidized purchase of insurance through state or federal exchange
- DEC = Decline
- Employee declines health insurance entirely.
- I = Ineligible
- Employee not eligible for health insurance due to:
- Temporary employee
- Part Time employee working less than 30 hours weekly
- Has not yet met the probationary period
Relationship (to employee) - Enter Self, Spouse or dependent
Only complete this page if your employees are interested in Life, Short-Term Disability, or Voluntary coverages.
- Class (fill in only for employees, family members aren’t required)
- Department or;
- Role within the organization.
- Life or Short-Term Disability (fill in only for employees):
- Hours per week: If an employee's hours fluctuate, and they are truly full time (ex: 25 hours one week, 40 another week and 60 another week), put at least 30 hours in this column. If the employee works 40 hours, indicate 40.
- Annual Earnings: The best source is last year's W-2. This includes hourly and commissioned employees. If an employee's W-2 does not reflect a full year or if an employee is new this year and does not have a W-2, estimate what the annual salary would be.