Agents Forms | AvMed

AvMed makes it easy to manage your account by providing forms and other tools for making requests. Simply print and fill out one of our pre-composed forms for quick, easy service. Certain requests can be submitted directly online.

Small Group Forms

Affidavit of Extended Dependent Eligibility
PDF, 129 KB Last Updated: 11/04/2024
PDF, 129 KB Last Updated: 11/04/2024
Appointment of Representative Form
PDF, 55 KB Last Updated: 03/26/2025
PDF, 55 KB Last Updated: 03/26/2025
Employee Status Change Form
PDF, 223 KB Last Updated: 03/06/2025
PDF, 223 KB Last Updated: 03/06/2025
Medical Direct Member Reimbursement Request Form
PDF, 201 KB Last Updated: 03/25/2025
PDF, 201 KB Last Updated: 03/25/2025
Member Disclosure Form
PDF, 208 KB Last Updated: 05/04/2025
PDF, 208 KB Last Updated: 05/04/2025
Employee Waiver of Coverage
PDF, 97 KB Last Updated: 03/06/2025
PDF, 97 KB Last Updated: 03/06/2025
Employer Risk Questionnaire
PDF, 181 KB Last Updated: 11/04/2024
PDF, 181 KB Last Updated: 11/04/2024
Employee Enrollment Form
PDF, 114 KB Last Updated: 03/06/2025
PDF, 114 KB Last Updated: 03/06/2025
Transition of Care - Non-Participating Provider
PDF, 112 KB Last Updated: 11/04/2024
PDF, 112 KB Last Updated: 11/04/2024
Continuation of Group Health Product (Fewer than 20 Employees)
PDF, 170 KB Last Updated: 11/04/2024
PDF, 170 KB Last Updated: 11/04/2024
Common Ownership Form
PDF, 93 KB Last Updated: 02/28/2025
PDF, 93 KB Last Updated: 02/28/2025
COBRA Application
PDF, 206 KB Last Updated: 02/28/2025
PDF, 206 KB Last Updated: 02/28/2025
PEO / Employer Questionnaire
PDF, 122 KB Last Updated: 11/04/2024
PDF, 122 KB Last Updated: 11/04/2024
Submission Deadline Calendar (Small Group)
PDF, 41 KB Last Updated: 02/28/2025
PDF, 41 KB Last Updated: 02/28/2025
Small Group Case Submissions (2-50 Employees)
PDF, 53 KB Last Updated: 02/28/2025
PDF, 53 KB Last Updated: 02/28/2025
Master Application (Small Group)
PDF, 298 KB Last Updated: 02/28/2025
PDF, 298 KB Last Updated: 02/28/2025
Underwriting Guidelines (Small Group)
PDF, 126 KB Last Updated: 05/05/2025
PDF, 126 KB Last Updated: 05/05/2025

Large Group Forms

Affidavit of Extended Dependent Eligibility
PDF, 129 KB Last Updated: 11/04/2024
PDF, 129 KB Last Updated: 11/04/2024
Appointment of Representative Form
PDF, 55 KB Last Updated: 03/26/2025
PDF, 55 KB Last Updated: 03/26/2025
Employee Status Change Form
PDF, 223 KB Last Updated: 03/06/2025
PDF, 223 KB Last Updated: 03/06/2025
Employee Enrollment Form
PDF, 114 KB Last Updated: 03/06/2025
PDF, 114 KB Last Updated: 03/06/2025
Medical Direct Member Reimbursement Request Form
PDF, 201 KB Last Updated: 03/25/2025
PDF, 201 KB Last Updated: 03/25/2025
Member Disclosure Form
PDF, 208 KB Last Updated: 05/04/2025
PDF, 208 KB Last Updated: 05/04/2025
Employee Waiver of Coverage
PDF, 97 KB Last Updated: 03/06/2025
PDF, 97 KB Last Updated: 03/06/2025
Employer Risk Questionnaire
PDF, 181 KB Last Updated: 11/04/2024
PDF, 181 KB Last Updated: 11/04/2024
Transition of Care - Non-Participating Provider
PDF, 112 KB Last Updated: 11/04/2024
PDF, 112 KB Last Updated: 11/04/2024
COBRA Application
PDF, 206 KB Last Updated: 02/28/2025
PDF, 206 KB Last Updated: 02/28/2025
Submissions Checklist (Large Group)
PDF, 70 KB Last Updated: 11/04/2024
PDF, 70 KB Last Updated: 11/04/2024
Commission Rate Agreement (Large Group)
PDF, 89 KB Last Updated: 11/04/2024
PDF, 89 KB Last Updated: 11/04/2024
Underwriting Guidelines (Large Group)
PDF, 25 KB Last Updated: 04/01/2025
PDF, 25 KB Last Updated: 04/01/2025