Group Health Form Group Health Insurance Form Employer Name Address Phone Benefits Administrator Contact Email Full Time-Equivalent Number of Employees (A full-time employee is one who works an average of 30 or more hours per week) Total number of eligible employees being offered coverage Number of employees age 65 or older or on Medicare Total number of employees waiving coverage Is your group offering other group health insurance coverage? Yes No Payroll Provider Payroll Contact Email Submit If you are human, leave this field blank.
