Employer Resources

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 2019
February 2019
March 2019
April 2019
May 2019
June 2019
July 2019
August 2019
September 2019
October 2019
November 2019
December 2019

Employers

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.

Is your doctor in your network?