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HEALTH BENEFITS PLAN CENSUS FORM Group Name: Company ... 2026

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The document is a Health Benefits Plan Census Form designed for organizations to collect information about their employees and their dependents for health insurance purposes. It includes fields for group name, company address, contact details, effective date, number of subscribers, and individual subscriber information such as name, date of birth, gender, tier classification, and zip code.

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Click ‘Get Form’ to open the HEALTH BENEFITS PLAN CENSUS FORM in the editor.
Begin by entering the Group Name and Company Address in the designated fields. Ensure all information is accurate for proper identification.
Fill in the City, State, and Zip Code. This information helps in categorizing your company’s location.
Provide details for the Contact Person, including their Phone, Fax, and Email. This ensures that communication regarding benefits can be streamlined.
Indicate the Effective Date and Number of Subscribers. This section is crucial for tracking enrollment periods.
In the table provided, list each subscriber's Name, Date of Birth (MM/DD/YYYY), Gender (M or F), Tier (EE, EC, ES, Fam), and their 5-Digit Zip Code. Make sure to provide accurate home zip codes as required.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What does group name mean on an insurance card?

Member ID Number: identifies you, the insured. Group number: Identifies your employer plan. Each employer choses a package for their employees based on price, or types of coverage. This is identified through the group number. If you purchased your insurance through the health exchange you might not have a group number.

What does it mean by group name on insurance card?

A Group Health Plan (GHP) is health insurance offered by an employer, union or association to its members while they are still working. GHP coverage is based on current employment.

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