1.) Company Information:

Company Name:

Address:

City:

State:

Zip Code:

County:

2.) Contact Information:

Company Contact Name:

Phone Number:

Email:

4.) Employee Information:

Number of Employees:

Number of Employees Eligible for Coverage:

5.) Please download the following Excel file and list all individuals who would be receiving benefits:
Aetna 2025 Sales Gateway Census Template.xlsx

Once complete, save the file and please upload it here:

Δ