Group Transmittal Sheet Template
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1
2Group Transmittal Sheet
Group Information
Group Name
Group Number
Address
City
State
Zip
Prepared By (Last Name, First Name)
Title
Date
Effective Date
Contact Number
TO BE COMPLETED BY EMPLOYER
Terminations
Check Appropriate Box
H/W,
Total # of
SSN/I.D. #
Employee Name
Remarks
Single
Family
P/C or
Persons
Enrollments
Check Appropriate Box
H/W,
Total # of
SSN/I.D. #
Employee Name
Remarks
Single
Family
P/C or
Persons
Changes
Check Appropriate Box
H/W,
Total # of
SSN/I.D. #
Employee Name
Remarks
Single
Family
P/C or
Persons
Over g
"PRINT OR TYPE ALL INFORMATION"
333 Earle Ovington Blvd., Suite 300 w Uniondale, New York 11553-3608 w
P 800-468-0608 ♦
F 516-227-0582
F-2005
Print Date 2-12
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Parent category: Legal