Hometown Health and Senior Care Plus

Resources

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) | Spanish (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)

COBRA Forms

iSolved Full Service Agreement

English (PDF)

iSolved Full Service Agreement with Employee Navigator Option

English (PDF)

iSolved Full Service Agreement for The Builders Association Health Plan

English (PDF)

Member Forms

Hometown Health Brokers

Small Group Forms

New / Renewing Small Group Checklist

Use this form for submission of a new or renewing small group.

Small Group Census Template

An excel-based template for small group census.

Hometown Health Brokers

Large Group Forms

New Large Group Checklist and Documents

Use for submitting a new large group.

Large Group Census Template

An excel-based template for large group census.

Medical Assessment Form (51+)

Use only if a group cannot provide claims experience.

Medical Assessment Form (51+) (Spanish)

Use only if a group cannot provide claims experience.

Dog and Senior Care Plus member pose at the lake

Medicare Forms

Scope of Appointment Form

For use when contacting Medicare Advantage prospects.

Broker Resources

We value your contributions to Hometown Health and Senior Care Plus, thank you for being our partners in health insurance.

Quotes
Manage your individual, family and commercial group sales and renewals.
Quoting Process

Compliance
All broker partners are expected to understand and follow our compliance policies.
Compliance Policies

Medicare Testing
For initial approval and recertification, complete the broker test.
Medicare Certification

We Value our Brokers
Reach out to our team, we want to hear from you.
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