Submit Files

Please include the following documents in your file upload:

Your Privacy and Security Matter to Us: At Statewide Purchasing Alliance of NY, we prioritize the protection of your sensitive information. Our website forms are fully HIPAA compliant, ensuring that any data you submit is securely encrypted and protected in accordance with the highest industry standards.

  1. Entity Name, Address, and Contact Information
  2. Letter of Intent (see sample)
  3. Census
    1. Retiree Name
    2. Date of Birth
    3. Address (Physical and Mailing)
    4. Phone Number of Retiree
    5. Medicare ID Number
    6. Gender
  4. Excellus AGIF Form and Signed Rate Sheet (Specific to selected Plan)
  5. Signed Broker of Record Form (July 1, 2026) or Broker of Record Form (January 1, 2027) – *Based on the Implementation Date*

"*" indicates required fields

Contact Name*

File Uploads

Please provide list of names of all files being uploaded.
Max. file size: 2 GB.
Max. file size: 2 GB.
Please see an example Census Information file here.
Include Retiree Name, Date of Birth, Gender, Address (Physical and Mailing), Phone Number of Retiree, Medicare ID Number (MRN Number)
*NOTE: If you are using a different format and need to submit separately, please contact Jacob Bulman at (607) 206-6513.
Max. file size: 2 GB.
Please see an example Excellus AGIF Form file here.

Annual Group Information Form

This form captures Contact and Critical Information for Onboarding.