Online Group Size Questionnaire

	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 (add total from 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

Employers

Are you part of a group of affiliated employers? Yes No

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

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.