Forms Center
Important Forms for Health Insurance Brokers
Enrollment & Eligibility Forms
- Enrollment Change Form
- Use to make changes to a group’s enrollment. For example: add, terminate or change an employee or dependent’s coverage.
- English (PDF) | Spanish (PDF)
- Enrollment Change Form – Individual and Family
- Use to make changes to an Individual and Family Policy during the year when dependents have a Qualifying Life Event.
- English (PDF)
- Waiver of Health Coverage Benefits
- Use this form for each employee who is waiving coverage. Be sure to have the employee provide a copy of his/her insurance card, if applicable.
- English (PDF) | Spanish (PDF)
- Commercial Group Application
- Use this form to begin a small group or association health plan application.
- English (PDF)
- Eligibility and Payment
- Use during open enrollment period to make changes to eligibility provisions.
- Group Eligibility and Payment Provisions (PDF)
Small Group Forms
- New / Renewing Small Group Checklist
- Use this form for submission of a new or renewing small group.
- English PDF
- Small Group Census Template
- An excel-based template for small group census.
- Excel Document
Large Group Forms
- New Large Group Checklist and Documents
- Use for submitting a new large group.
- English PDF
- Large Group Census Template
- An excel-based template for large group census.
- Excel Document
- Medical Assessment Form (51+)
- Use only if a group cannot provide claims experience.
- English PDF
- Medical Assessment Form (51+) (Spanish)
- Use only if a group cannot provide claims experience.
- Spanish PDF
Medicare Forms
- Scope of Appointment Form
- For use when contacting Medicare Advantage prospects.
- English PDF
