Employers

Online Group Size Questionnaire

Report your monthly employee counts so WPS can meet federal reporting and compliance requirements for your group.

Why we’re asking.

Federal law requires WPS to determine each employer group’s size based on the number of employees it had during the prior calendar year. Your answers help us apply the correct rules to your plan — including Medicare Secondary Payer, the Affordable Care Act and other federal requirements.

Please complete every field below. If a month had no employees in a category, enter 0. When you’re finished, enter your name as your legal signature and select Submit.

Please fill in the following employer information.

Group Number

Subgroup Number

Monthly employee counts

Enter the number of employees as of the end of each month. The combined total for each row is calculated automatically.

Month	Column A. Total number of full-time employees (as of the end of the month)	Column B. Total number of part-time employees (as of the end of the month)	Column C. Others not reported in Column A or B	Combined total (Columns A + B + C)
January 2025
February 2025
March 2025
April 2025
May 2025
June 2025
July 2025
August 2025
September 2025
October 2025
November 2025
December 2025

Are you part of a group of affiliated employers?

Yes No

If yes, please explain

In the last year, has your total employee count increased to 20 or more employees or decreased to 19 or fewer employees?

Increased to 20 or more employees Decreased to 19 or fewer employees No

Group Information

Full Legal Name of Employer

Address

City

State

ZIP

County

Employer Identification Number (EIN) / Tax Identification Number (TIN)

Employer Email Address

Phone Number

Employer Verification

Group Leader First Name

Group Leader Last Name

Group Leader Title

Group Leader Signature By entering your name here, you are giving your legal signature.

Thank you for your cooperation in this important federal compliance matter. Questions? Please contact Customer Service at 888-672-0062.