Enter Your Employee Census
Questions? Call 1.800.930.7956
Corporate Information
Company Name
Contact Name
Phone Number
Email
Corporate Zip Code
CSV File Title
Employees and Dependents
List any spouses or dependents directly below the corresponding employee.
First Name
Last Name
Relationship
Employee
Spouse/Partner
Child/Dependent
Date of Birth
Gender
Male
Female
Home Zip Code
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Once you click Submit, you will be redirected to the Regal Benefits home page.
