Online Group Size Questionnaire

Please fill in the following employer information:

	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 2022
February 2022
March 2022
April 2022
May 2022
June 2022
July 2022
August 2022
September 2022
October 2022
November 2022
December 2022

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 None

Group Information

Employer Verification

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 Member Services Administration at 888-672-0062.

Online Group Size Questionnaire

Employer Navigation

Online Group Size Questionnaire

Please fill in the following employer information:

Employers

Group Information

Employer Verification

Is your doctor in your network?