Page Title

Group Health Insurance Applications and Forms

PLEASE NOTE: FORMS ARE CONSTANTLY BEING UPDATED AND
CHANGED...PLEASE MAKE SURE THAT YOU ARE USING THE MOST RECENT
FORM AVAILABLE....IF YOU ARE UNSURE ABOUT SOMETHING, PLEASE GIVE US
A CALL!!!

CAREFIRST/BLUE CROSS

Carefirst HMO/Open-Access-Employee Application

Carefirst HMO/Open Access-Group Application

Coventry Employee Application

Coventry HMO/POS Group Application

Coventry Employee PPO Application

Coventry-Small Group Employer Contract

ASSURANT

Assurant-Employee Application

Assurant Employer Application

Assurant Health-Risk Management Agreement

Assurant Health-HSA Enrollment Form

KELLY AND ASSOCIATES

Kelly and Associates-Employee Application

Kelly and Associates-Change/Termination Form

Kelly and Associates-Group Insurance Agreement

KAISER PERMANENTE

Kaiser Permanente-Small Group Employee Application

Kaiser Permanente-Employee Medical Questionnaire

Kaiser Permanente-Small Group Employer Application-MD

Kaiser Permanente-Small Group Employer Application-DC

Kaiser Permanente-Small Group Employer Application-VA

Dental Applications and Forms

Dental Network-Employee Application

Dental Network-Group Application

DentaQuest Individual Select Plan Rates/Application

United Concordia-PPO Enrollment Form

Individual Health Insurance Applications and Forms

Kaiser Permanente-Individual Application

Kaiser Permanente-Individual Medical Questionnaire

Plan Selection Form

Blue Choice HMO-Individual Application

Personal Comp-Individual Application

Blue Preferred Saver-Individual Application

Aetna-Indivdual Application

Assurant Individual Application

Lg. Group Risk Questionnaires/Misc. Questionnaires

Coventry-Risk Questionnaire

Carefirst-Risk Questionnaire

Assurant Health-Back Questionnaire

Benefit One-Group Risk Questionnaire

General/Miscellaneous Forms

EMPLOYEE CENSUS FORM

COBRA INFORMATION PACKET (Includes Templates/Forms for Employer Use)

Doctor Network Inquiry Form

Carefirst-Mail Order RX Form

Carefirst-Argus RX Claim Form

Carefirst-Release of Information Authorization Form

Carefirst-Student Certification Form

Coventry-Release of Information Authorization Form

Coventry-Caremark RX Mail Order Form

Assurant Health-MEDCO Mail Order Form

Assurant Health-Termination/Change Form

Life Insurance Applications and Forms

(REFUND OF PREMIUM RATES)

Female Rate Card Non-Tobacco -Premier 20

Female Rate Card Tobacco -Premier 20

Male Rate Card Non-Tobacco -Premier 20

Male Rate Card Tobacco -Premier 20

UHL Term Life Application

UHL Replacement form

Rate Cards for Males and Females - Express Issue Term Plu s -(Non-refund of premium)

Carefirst-MEC Vision Claim Form

Mortgage Certification Form

MetLife-Small Group Employee Application

MetLife-Small Group Employer Contract

MetLife-New Group Submission Checklist

Child Rider Application

MAMSI-Risk Questionnaire

Kaiser Permanente-Risk Questionnaire

Coventry-Caremark RX Reimbursement Form

COVENTRY

Assurant Health-Cancer Questionnaire

Assurant Health-Administrative Services Agreement

United COncordia-DHMO Enrollment Form

Kaiser Permanente Lg. Group HMO application

Kaiser Permanente Lg. Group POS/Indemnity Application

Assurant Health-Short Term Policy-Application/Brochure

Short Term Policy