Group Profile Questionnaire

Group Questionnaire

Step 1 of 5

Complete your Company Profile below (4-5 minutes to complete) and execute the Agreements via electronic signature.

Complete your Profile and then upload your Employee Census information and we will get your Application processed within 48 hours of having all of the signed Application Documents, complete Employee Census data, and Payment Authorization.

Note that Enrollments received before the 25th of the month, will be effective the 1st of the immediately following month (ex. June 24 enrollment gives July 1 Effective Date).
  • Enrollments received after the 24th of the month, will be effective the 1st of the second month following the enrollment date (ex. June 25 enrollment gives August 1 Effective Date).
  • Effective Dates that are entered which do not comply with the aforementioned timing, will be automatically adjusted to reflect the appropriate Effective Date.
Plan Type To Be Offered
Do you have a single point of contact or multiple contacts for Billing, Eligibility, HR/Benefits?
Do you have a Broker or Agent that you are using for this Benefit?
Is your company part of a Control Group?
Do you currently offer a Health Care plan(s)?
Do you Define Classes of Employees?
Many employers establish different classes of employees (management, administrative, temporary, Sr. or Jr. workers, interns, etc.) to create a visible incentive to advance in the company. Many companies do not define classes of employee, so if you do not, smile, it's ok.
Do you have the authority to sign agreements on behalf of the company or is there a different Legal Representative for signing legal documents?
Are you looking for coverage in any of the following states?
After you complete the Group Profile above, upload your employee data for quoting:
  • Once your profile above is complete and click the Submit button, you will be asked to review and securely execute the Xpress Agreements via electronic signature.
  • Once completed, Download the Census Template spreadsheet to your local drive
  • Enter your employees’ information into the Census.
    • Do not enter anything in the Red or Blue columns; Green is mandatory and Yellow is optional.
  • Once you’ve completed the Census, upload your file using the Upload Feature to the right.
  • Once your Group Profile is complete, Agreements executed, and you submit the Census for review, we will begin processing your Group’s Application for benefits.

Contact if you have any questions or trouble with downloading or completing the Census.

Upload File
Drop files here or
FORM #NB-NB19053