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Annual Group Information Form

GLO-BRK-Group Information Form - Main Content

For a full comprehensive guide of Annual Group Information Forms, please refer to the following instructional PDF's:

For Small Groups:

You can now submit your group information 1 of 2 ways:

Option 1:

Fill out and submit your group's information electronically with our online Group Information Form (Login Required)

Please Note:
If you do not currently have access to the online AGIF tool, please submit a request through our

Please Note:
If you do not currently have access to the online AGIF tool, please submit a request through our

Group administrators will also need online access to AGIF tool to complete sign off.

Option 2:

Download and complete Group Information FormOpen a PDFGroup Information FormOpen a PDF

Once your form is complete and signed by your group administrator, please email the form to:


For Large Groups:

You can download and complete your form and send to your account representative.

Download and complete Group Information FormOpen a PDF

Download and complete Group Information FormOpen a PDF

 

Additional Important Information:

Due to various state and federal regulations, Excellus BlueCross BlueShieldUnivera Healthcare is required to obtain certain information regarding your group on an annual basis. As your health insurance provider, we know this information as it relates to the members you have with us, but we may not have an accurate understanding of this information as it applies to all of your employees. We appreciate your cooperation in providing this information. If needed, we may use this information to generate a Master Group Agreement.

If you have any questions please contact your account consultant or call 1-888-817-2700.

GLO-EMP-BRK-Group Information Form - Modal Content

Modal for Additional Group Information