Census Information

The census is a list of the employees and/or dependents that are to be quoted/covered. The needed information is a description of who (employee (EE), dependent and type ie Sp (spouse) or CH (child(ren). Next, please enter first initial and last initial, gender, date of birth and home zip code. At the far right are columns for annual income and job description for coverage such as short-term and long term disability should they be desired.

Once completed along with the questionnaire, please send to David H. Romero via Email at [email protected], fax to (310) 322-3547 or regular mail to DHR Insurance Services, Inc., 302 W. Grand Ave Suite 8, El Segundo, CA 90245.
 

Census Form
(Excel file download)

Questionnaire
(Fillable PDF file)