Please provide the below information and you will be contacted by the program administrator. Required fields are marked with an asterisk (*) What is your favorite color? Group name: * Email address: * Phone: * Address: * Address City State ZIP Code Employer contribution: Probationary Period: Minimum hours worked: hrs. Effective date: * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year202420252026 Year Upload a completed census form document Download the Excel Census template and fill out the appropriate fields. Save the file on your computer and upload it here. Only .xls .xlsx or .csv formats are acceptable. More informationFiles must be less than 2 MB. Allowed file types: xls xlsx csv. Upload Agreement * I (the group administrator or owner) of the above group have completed the above information to the best of my knowledge and I realize that final rates are based on final enrollment. If the above information is not complete or incorrect it might affect the final rates upon enrollment. Submit
