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Broker News | November 2015 | Vol. 10 No. 10
Broker News | November 2015 | Vol. 10 No. 10

Annual Group Information Form (AGIF) Mailing Update

We need your help!

In order for us to have the most up-to-date information, please complete the questionnaire and return it to us by March 1, 2016.

You will need your unique Employer Group Number and Group Name when submitting your completed information.

How to Submit Your Annual Group Information Form

Using our formatted Adobe PDF file template, you can easily enter your group information and save it.

  1. Save the Group Information Form (AGIF) template to your computer. You will need Adobe Acrobat to work with this file.

    >> Annual Group Information Form (PDF)

    If your group has individuals with retirees who are offered a Medicare Advantage or a Retiree Health Plan product with our health plan, please complete and submit the additional Medicare Questionnaire.

    >> Medicare Questionnaire (PDF)

  2. Follow the instructions for our AGIF to prepare your file for submission.

    >> Instructions (PDF)

    >> Medicare Instructions (PDF)

  3. Email your completed Group Information Form (AGIF) to AnnualGroupInformation Excellus@excellus.com

    If you prefer the Annual Group Information Form to be mailed to you for completion, please contact us via  or call us directly at 1-888-817-2700.If you prefer the Annual Group Information Form to be mailed to you for completion, please contact us via email or call us directly at 1-888-817-2700.

Why are we asking for this information?

Due to various state and federal laws and regulations, Excellus BlueCross BlueShield is required to obtain certain information regarding your group on an annual basis.

As your health insurance provider, we may have 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 as a group.

We appreciate your cooperation in providing this information. If needed, we may use this information to generate a Master Group Agreement.

Please note: Employer groups are responsible for providing accurate information to the health plan in a timely manner. Employer groups will be held accountable for the payment of any penalties imposed on the health plan as a result of inaccurate or misleading information supplied by the group or the group's failure to provide the requested information.

Why is this important?
Please read for more details. (PDF)

If you have any questions, please contact your account consultant, broker, or Chamber Trust & Association administrator.


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