MightyWELL Plan Census
Affordable Flexible Transparent Robust Healthcare
Company Name
*
Company Contact
*
First Name
Last Name
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Email
*
example@example.com
MightyWELL Representative
*
First Name
Last Name
Rep Email
example@example.com
Please upload your census, Excel document preferred
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If you do not have a census to upload please list your employees below.
Employee Names
Name
DOB
Gender
Tier( EE, ES, EC, EF)
Zip code
1.
2.
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