ICHRA Census Form
Quick start for new brokers: download it, fill it in for your group, send it back.
Quick start for new brokers
How it works
-
Download the form
An Excel spreadsheet with one sheet, titled “Employer Census”.
Download the census form (XLSX) -
Fill it in for your group
The company’s details, the contribution you pick, and one row per person.
What the form asks for -
Send it back
By email or fax, to the contacts printed on the form.
Where to send it
What the form asks for · 1 of 3
Company details
Six details about the company.
- Name
- Address
- Zip Code
- Contact Person
- Phone number
- Email address
What the form asks for · 2 of 3
Company contribution: pick one
The form offers seven strategies. Each one is quoted here exactly as the form words it.
Percentage of a plan
-
Generous
Employer pays 80% of Highest Silver Plan for Employee and Dependents.
- Employer pays
- 80%
- Plan
- Highest Silver
- For
- Employee and dependents
-
Good with Family members
Employer pays 70% of Lowest Silver Plan for Employee Only and 40% for Dependents.
- Employer pays
- 70% and 40% for dependents
- Plan
- Lowest Silver
- For
- Employee and dependents
-
Good, Employee Only
Employer pays 70% of Lowest Silver Plan for Employee Only.
- Employer pays
- 70%
- Plan
- Lowest Silver
- For
- Employee only
-
Medium
Employer pays 50% of Lowest Bronze Plan for Employee Only’s.
- Employer pays
- 50%
- Plan
- Lowest Bronze
- For
- Employee only
-
Low
Employer pays 10% of Lowest Bronze Plan for Employee Only. May allow some older and lower paid employees to go to the Exchange for Tax Credits.
- Employer pays
- 10%
- Plan
- Lowest Bronze
- For
- Employee only
Lump amount
-
Lump Amount, Family
Employer pays up to a single amount for each Family. $ (blank for the amount)
- Employer pays
- Up to a single amount
- Plan
- No plan named
- For
- Each family
-
Lump Amount, Employee Only
Employer pays up to a single amount for each Employee Only. $ (blank for the amount)
- Employer pays
- Up to a single amount
- Plan
- No plan named
- For
- Each employee only
What the form asks for · 3 of 3
Census: one row per person
Eight columns, two of them optional. Each person is marked as an Employee (E), Spouse (S) or Child (C).
| First Name | Last Name Optional | Relationship E, S or C | Date of Birth MM/DD/YYYY | Home Zipcode | Gender M/F | Tobacco Y/N | Gross Income $/yr Optional |
|---|---|---|---|---|---|---|---|
Send it back
Send us the completed form
The same email address and numbers are printed on the form.
- Email sean@ichrasystems.com
- Phone 303-782-0123
- Fax 303-782-0804
Back to the Broker Portal
Everything you need to quote, certify and administer an ICHRA.