Group/Employer Health Forms and Applications

2024

BC Waiver Form

IBC Small Employer Cert. Form

BC Eligibility Form

IBX Broker of Record

2024 IBX Employer App for New 2-50 Small Employer Coverage

2024 IBX Employee Application for 2-50 Small Employer Coverage

2024 IBX NSB Checklist

2024 IBX Blue Solutions Portfolio

IBX Employee Application

IBX Blue Solutions

2023

2023-small-group-portfolio-marketing-brochure

IBX Broker of Record (BOR) Form 2021 (004)

2023 IBX Employee Application for Small Employee 2-50 Coverage

2023 IBX Employer Application for New Small Employer 2-50 Coverage

BC Eligibility form

BC Waiver Form

IBC Small Employer Cert. Form

2022

2022 employee IBX Plan Brochure

2021

2021-blue-solutions-renewal-savings-form

IBX 2020

IBC 2020 Group Checklist

2020 Application Small (Employee)

2020 Application Small (Employer)

BC Waiver Form 2020

BC Eligibility Form 2020

IBC BOR FORM 2020

2020 Blue Solutions Brochure

2020 Blue Solutions Renewal Guide

2020 Renewal and Savings Form

Benefits Plan Comparison In network 2020

College Tuition Benefit Flyer

eBill Customer Flyer

Keystone HMO Proactive Tiered Network Flyer

Renewal Form

Tips on applying:

• Make sure to include the current UC2A report and eligibility form/ownership docs for the owner if owner is not on the UC2A report (See Eligibility Form for acceptable owner docs).
• On The UC2A report, please write the employee statuses next to their names– part-time, full-time, termed.
• If any full-time employees on the UC2A report are waiving,  a waiver form must be completed.
• Make sure to include a signed copy of the quote with plan selection listed.
• No check needed for IBC- group, you will be invoiced for first premium
• On the new IBC BOR/Online access form, the “Producing Agent” box should be checked off on page 2

Aetna

AFA Small Group New Business Checklist 2020

AFA New Business Submission Process 2020

SBMP Template v9

Data Software License Agreement 2020

AFA Billing and Banking Handbook ABA-EBS 2020

AFA Employee App

__________________

national_cposii_az_ppo_2017_benefit_grid

need the attached paperwork

Aetna AFA Customer Info Request Form- Blank

AFA Banking Consent Form (ACH)

AllSavers.benefit.grid

AFA-Paperless-Process Submission Info

AFA_Employer_Application_1 5-17

AFA PA STOP LOSS (3-3)

AFA HCRA

national_cposii_az_ppo_2017_benefit_grid AFA

DataSoftwareLicenseAgreement

Springboard- AHIA-FSR User Template

SG AFA Springboard Census and Setup Template 11-17

afa_billing_and_banking_explanation

Aetna 1-50 Brochure

Aetna 1-50 Savings + Brochure

Aetna PA benefit grid 2017

Vision Flyer

Aetna 51-100 Savings + Brochure

51-100 at a Glance

Tips:

For Aetna AFA medical, some of the forms are electronic, but here is the checklist (the employer app and HCRA are DocuSigned).

In addition to attached, we need (after the Sales Notification is submitted)—

• Aetna proposal – please  circle selected plans, sign and date
• Copy of the group’s most recent prior carrier bill
• Group’s under 5 enrolling require the annotated UC2A report

Please note before a group can apply for Aetna AFA, they need to be medically underwritten, and then we submit a sales notice (last attachment) when they are ready to apply. We can run preliminary quotes first though.

UnitedHealthcare®

2020

Employer Application 2020

Employer eServices Scheduled Direct Debit

Employee Enrollment Form 2020

Above is fully insured 2020 UHC paperwork.

• On the the direct debit form. ACH is optional for groups of 4+ enrolling and required for under 4 enrolling.
• If not paying with ACH/ 4+ enrolling, then include the first month’s premium check made payable to UnitedHealthcare®
• Need the signed rates with their plan selection
• Need current UC2A with employee statuses marked (Part-time, Termed, Full-time Waiving)
• If the owner does not appear on the UC2A we will need proof of ownership such as a K-1 or schedule C.
• Need payroll for any new hires who do not appear on the UC2A

All Savers 2020

AS ER App

AS NY form

AS NY Payor Form

AS Spec Comb Group app

AS App for Excell Loss Ins

AS Billing and Coll agree

AS Docusign Guide

For UHC AllSavers (Level-Funded) 2020 new group, we need the following–

• Employer medical Application
• ER Excess Loss Form
• ER vision/Dental app
• Current medical, vision and dental  carrier bill
• Billing Agreement Form
• NY Forms (Level-Funded Requirement)
• Employee Medical Enrollment Form (or there is an Excel enrollment template that can be used if needed)
• Check made payable to UnitedHealthcare®
• UC2 Report – Quarterly tax and and wage statement
• A copy of sold rates (note: sold rates should be the medically underwritten rates, not the initial street quote).
• Term letter on company letterhead, signed and date (if you want us to submit to the current carrier)
• If selecting AllSavers’ HSA Bank there is additional paperwork (not included)

Before applying, the group needs to be medically underwritten with UHC.

AS EE App

employer 50 plus application

Employer Participation & Floor Certification

Group Vision

UHC BOR

HIPPA Form

Employee App LG

MYUHC.com

ER App LG

Billing Agreement

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