Forms

View and print a list of forms you will need when working with Small Groups.

• Appointment of Representative (Group members)
• Employee Status Change Form (English)
• Employee Status Change Form (Español)
• Employee Enrollment Form (English)
• Member Disclosure Form
• Pharmacy Transition of Medications
• Waiver of Coverage
• Employer Risk Questionnaire
• Medical Transition of Care
• HIPAA Plan Sponsor Certification Form

• Continuation of Coverage (mini-cobra)
• Common Ownership Form
• COBRA form English
• COBRA form Spanish
• Contractor Relationship - 1099 Affidavit  (Word template)
• Creditable Coverage Form
• Employee Census
• Employer Risk Questionnaire (Required for groups of 10-50)
• PEO Questionnaire Form
• Individual Medical Questionnaire (Required for groups of
  1-9; Optional for groups of 10-50)
• Small Group Master Application
• Small Group Submission Deadline Calendar 2012
• Small Group Underwriting Guidelines
• Small Group Checklist