Forms & Information

Forms

Applications

• 2017 Small Group Member Application
• 2016 Large Group Member Application

Enrollment

• Add/Change/Delete Form
• New Business Submission Checklist
• Group Attestation
• Waiver of Coverage

Documents & Information

Eligibility Requirements

• Small Group Eligibility Requirements
• Individual Eligibility Requirements
• Large Group Eligibility Requirements

Group Correspondence Templates

• Group Acknowledgement Letter - Sample
• Group Late Payment Notice - Sample
• Group Termination Notice - Sample
• Group Termination Letter - Sample
• Large Group Member Discontinuance Notice – Sample
• Large Group Policyholder Discontinuance Notice – Sample
• Small Group Member Discontinuance Notice – Sample
• Small Group Policyholder Off Exchange Discontinuance Notice – Sample
• Small Group Policyholder On Exchange Discontinuance Notice – Sample