Premium Reporting Form

SECTION A - Group Information

In accordance with Consolidated Appropriations Act of 2021 (Section 204), health plans are required to submit information to the federal government regarding the average monthly premiums paid by employers on behalf of enrollees and paid by enrollees each year. Use this Sutter Health Plus Form to report this information.

If you have any questions about how to complete this form, please call Sutter Health Plus Member Services at (855) 315-5800.

Legal Company Name *
DBA (Account Name) *
Group Account ID *

Submitting on Behalf of Group *

	Broker
	Employer

Print Name *
Title *
Email *
Phone (000-000-0000) *
Date *